Clinical leadership in service redesign using Clinical Commissioning Groups: a mixed-methods study

Article history

The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 12/136/104. The contractual start date was in December 2013. The final report began editorial review in December 2016 and was accepted for publication in May 2017. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of authors

none

Copyright statement

© Queen’s Printer and Controller of HMSO 2018. This work was produced by Storey et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

2018 Queen’s Printer and Controller of HMSO

The wider context and the policy intent

The basic policy shift, which abolished primary care trusts (PCTs) and strategic health authorities and introduced local commissioning groups led by GPs, can be seen to build on three ideas: (1) clinical leadership, (2) the use of CCGs as a platform which gave them commissioning powers and (3) the idea that these actors would use these powers to improve the quality and cost-effectiveness of the NHS and to redesign services (indeed ‘transform’ them) to make them better suited to local needs, in more effective and sustainable ways.

The policy, its ensuing reform and its legislative package was hugely controversial. The whole edifice could be seen as a massive experiment. Handing the purse strings to new groupings of GPs and disbanding existing structures came as a surprise; it had not featured in the Conservative Party Manifesto of 2010. It became mandatory for GP practices to be part of, and indeed members of, a CCG. Our research project was designed to target a set of questions which went to the heart of the package of reforms. In essence, the underlying aim was to assess how clinical leadership in and around CCGs would operate in practice. By ‘operate’ we mean what it would deliver and how it would produce any achieved outcome. In order to answer these questions, the research design was built, centrally, around a study of initiatives in specific service areas in order to map these in a manner which dug beneath the rhetoric of reform. These service areas were identified by the wide range of stakeholder informants at the scoping stage as the ones most critical to the future viability of the NHS. The service areas identified were redesigning urgent care, managing long-term conditions, care of the frail elderly and mental health.

Our central concern was how clinicians used, and were affected by, the institutional mechanisms. Lessons learned in manoeuvring through and around these carry a significance beyond the specifics of the CCG formation. The story is bigger than CCGs alone. A considerable amount of activity was initiated by clinical leaders who were not in a formal post within a CCG.

In 2012/13, the idea of facilitating clinical leadership through localised commissioning bodies was not entirely new. Former experiments included GP fundholding and related forms. As we and others anticipated, it was not long after the official launch of CCGs in April 2013 that other initiatives and other developments emerged – most notably, the NHSE-led ‘New Models of Care’ (URL: www.england.nhs.uk/ourwork/futurenhs/new-care-models/; accessed 25 October 2017). All CCGs have had to take note of, and respond in some way to, these policy thrusts. Inevitably, our research work in and around CCGs tracked these responses as they occurred in real time.

During the period since their inception, there appears to have been increasing oversight and monitoring of CCGs, most especially by NHSE and the Care Quality Commission (CQC). Some CCGs have been put into special measures, senior staff have been displaced and Ofsted-style ratings have been used to identify CCGs needing improvement or deemed to be in the ‘greatest need of improvement’ (URL: www.nhs.uk/service-search/scorecard/results/1173; accessed 25 October 2017). An interesting feature here is the way local commissioners are being held to account by central agencies in addition to the accountability to the local membership. In 2017, a number of CCG mergers were approved and further mergers leading to fewer and larger CCGs are likely to follow.

The requirement on local health economies to construct sustainability and transformation plans (STPs) also represents a game-changing initiative concerning the redesign of health and social care. Although the STPs require engagement by CCGs, local authorities (LAs) and provider trusts, there are concerns that these bodies, creations of the centre, may come to diminish the influence of CCGs. 4 A PricewaterhouseCooper report notes that the consequence of multiple initiatives has been a ‘complex middle ground’ of localism and central direction. 5

The plans focus on some common themes: reductions in secondary care provision, closure or redesignation of community hospitals and revamped primary care with larger practices. 6 The promotion of new models, which emphasises integration and collaboration, seems to point to a lower priority for competition and commissioning and a higher priority for planning and collaboration. Indeed, the NHS chief executive refers to the possibility of the ‘pooling of sovereignty to drive the changes’ planned by STPs between commissioners and provider organisations. 7 Such developments might suggest that there is increasing uncertainty whether or not CCGs will, in the future, be regarded as the natural leaders of change and service redesign or become subsidiary to the STP level.

These profound ongoing shifts in the wider context were very much borne in mind by the members of the research team as they progressed with the task of finding answers to the original set of research questions. Those questions were as follows.

Research questions

The overall aim was to assess and clarify the extent, nature and effectiveness of clinical engagement and leadership in the work of the CCGs. This was broken down into five main research questions.

1. What is the range of clinical engagement and clinical leadership modes being used in CCGs?

2. What is the extent and nature of the scope for clinical leadership and engagement in service redesign that is possible and facilitated by commissioning bodies, particularly the CCGs and the health and well-being boards (HWBs)?

3. What is the range of benefits being targeted through different kinds of clinical engagement and leadership?

4. What are the forces and factors that serve either to enable or block the achievement of benefits in different contexts, and how appropriate are different kinds of clinical engagement and leadership for achieving effective service design?

5. What can be learned from international practices of clinical leadership in service redesign in complex systems that will be of theoretical and practical value to CCGs and HWBs?

The case studies and the national surveys were used as means to generate relevant data to help answer these questions. Before we present the findings and our interpretations of those findings, it is necessary to:

1. summarise the state of knowledge about these questions as found in the existing literature

2. introduce the theoretical lens we used in undertaking the analysis found in later chapters

3. describe the research methods which we deployed in this study.

In seeking to answer the research questions we were of course aware that there were existing literatures relevant to aspects of the research agenda, most notably literatures concerning the policy context, previous initiatives prompting GP commissioning, clinical leadership more broadly and service redesign in health. Hence, before describing our research methods we now turn to an outline review of those literatures.

The policy context

Policies can be seen as ‘answers’ to actual or perceived challenges facing health and social care, hence we begin this section with a brief review of the literature on those challenges. The predominant perceived challenges during the course of this study (2013–16) was the fragmented health and social care system and the severe financial constraints.

The nature and scale of the challenges facing the NHS have been spelled out many times,8 and there have been many warnings about the non-sustainability of business as usual. Currently, capital budgets are being constrained. In this environment, the ambitious transformation plans which usually require funding may be hampered by lack of money. Failures in the joining up of fragmented services are widely seen as having an impact on care of the frail elderly in particular. 9 On the demand side, the growing ageing population with multiple morbidities and wider population ill-health associated with obesity, diabetes mellitus and other long-term conditions are well-recognised problems for which new approaches to health and social care and, indeed, wider and far-reaching ‘health of the public’ innovations will be required. 10

The fortunes of the health service and the adult social care service are intertwined. A CQC report on the state of play in 2015–16 revealed that, because of funding cuts in local government and rising demand, adult social care services were at a ‘tipping point’. 11

The responses to these challenges have been many. A common theme has been a call for a new focus on prevention, more self-care, integrated health and social care and more home-based care. 12

The main policy intervention, as far as the CCGs as institutions are concerned, was the Health and Social Care Act 20122 which established CCGs and abolished PCTs and strategic health authorities. This expressed the policy intent of an apparent devolution of power and accountability. The CCGs could be seen as the institutional expression of the policy thrust which put challenge, competition, choice and commissioning to the fore.

However, following the departure of Secretary of State for Health, Andrew Lansley, in 2012, the emphasis shifted. Following the publication of the Mid Staffordshire Report,13 patient safety, patient experience and quality of care came more to the fore and so too a fundamental shift in policy towards integrated care, community-based care and ‘new models’ which gave primacy to collaborative working and meeting the needs of patients. 14

Variability in policy and practice during the research period were all too evident. Local commissioning runs alongside more regional planning. Local initiatives are fuelled by short-term special funding such as the Prime Minister’s Challenge Fund, the Pioneers, the Vanguards, the new Care Models and the STPs. Among other things, this means that interpretation of the role of clinical leadership in CCGs, and indeed interpretations of the role of CCGs themselves, need to take account of multiple shifts in the wider landscape of health and social care.

During 2016, NHSE modified the basis of NHS planning, requiring STPs to be produced within 44 ‘footprints’. These STPs are intended to provide the local planning basis for moving towards the models for integrated service delivery outlined in the Five Year Forward View. 12 This has enforced some clustering of CCGs. Many CCGs now work closely with their neighbouring CCGs and some share an accountable officer and other members of a managerial team.

The Health and Social Care Act 20122 and the surrounding policies and initiatives set the scene for much of the debate. A critical juncture in the highly contested passage of the Bill was the ‘Pause’ and the work of the NHS Future Forum. This raised, and explored, many of the issues which are now being worked through in practice by the CCGs and their surrounding bodies. 15

The NHS Commissioning Board which became NHSE, was responsible for the authorisation of CCGs and continues to oversee, guide and influence them. 16 In Planning and Delivering Service Changes for Patients17 it stated that major service changes and reconfigurations must put patients and public first and must be clinically led. It is clear that at that time of inception, CCGs were seen as the critical instrument and agency for driving change. NHSE gave further guidance relating to clinical leadership:

Chairs, Accountable Officers, Chief Executives and Medical Directors from across the organisations involved in a service reconfiguration should exercise collective and personal leadership and accountability when considering the development of proposals for major service change. Front-line clinicians and other staff should also be involved in developing proposals and in their implementation.

NHSE17 (emphasis added in bold).

Contains public sector information licensed under the Open Government Licence v3.0

Expectations were thus set high. It sets out a process for the planning, development and implementation of major service redesigns.

In April 2014, NHSE published its plans for transforming primary care. 18 It urged a move ‘away from providing 20th century solutions that are based on a fix and treat model’. This reflects an emergent theme, which was then developed in the Five Year Forward View. 12 This set out the direction of travel to guide local decision-makers with a strong emphasis on joined-up, integrated care. Notably, there is not a lot of emphasis on CCGs as institutional leads in the Five Year Forward View, although there is this statement of intent:

Give GP-led Clinical Commissioning Groups (CCGs) more influence over the wider NHS budget, enabling a shift in investment from acute to primary and community services.

NHSE. 12

Reproduced under the Open Government Licence

A growing policy emphasis is on general practice and the idea of an extended multidisciplinary team surrounding GPs. A key example is the General Practice Forward View. 19 This promised accelerated funding, an expanded workforce of GPs and a more diversified workforce mix surrounding GPs, practice infrastructure improvements and major programmes of care redesign. In 2016, NHSE and NHS Improvement published the NHS Operational Guidance for 2017/18 to 2018/19 under the title Delivering the Forward View. 20 This increases primary care allocations for general practice with recurrent funding to the General Practice Access Fund.

Ironically, despite the clear and emphatic policy intent, the continued influence of the acute sector continues to be felt. This was seen in relation to the STPs, with considerable influence allotted to acute sector leaders, and is seen also in the continued funding bias. There is also a continued high-demand pressure on hospitals.

Literature on Clinical Commissioning Groups

The literature on CCGs comprises reports on the predecessor bodies to the CCGs, which included early forms of GP fundholding and commissioning; literature on CCGs while they were in shadow form leading up to April 2013; and reports on the actual operation of CCGs since they became statutory bodies in April 2013.

Since the original purchaser–provider split in the NHS, introduced by the National Health Service and Community Care Act of 1990,21 there have been many variants of clinical commissioning. The GP fundholding scheme was voluntary and it allowed GP practices to take control of a budget for certain defined services along with funds for a practice management allowance. 22 The Act allowed for ‘fund-holding practices’, and there followed a series of pilots and experiments. Most notably, the pilots and experiments included GP commissioning using fundholding (from 1991), total purchasing (from 1995 to 1998), primary care groups (PCGs) (1999) and the authorisation of PCTs. Storey et al. 23 and Sheaff et al. 24 studied commissioning under PCTs; the latter research group also, to an extent, studied the transition into shadow CCGs and, in so doing, revealed a number of important features of the way it operated in England and to a degree in other countries.

The 23-year period from 1990 to 2013 included numerous pilots and new forms. There are many relevant lessons to be drawn from the experiments and from the related literature. This fact has been noted by some helpful meta-reviews by The King’s Fund,25–27 the Institute of Education, London,28 and by PRUComm (Policy Research Unit in Commissioning and the Healthcare System). 29

Most interpretations suggested that these early forms had modest impact, but that this stemmed more from the constraints placed on the experiments rather than from the concept itself.

Studies of CCGs in shadow form again reported much uncertainty around the link between the governance/assurance level and the operational level; about links with the wider GP membership; about how to resolve conflicts of interest; and about who could make decisions about what. 30 Other work drew lessons about the motivations of GPs, their levels of involvement, engagement and influence, and of leadership by clinicians under each of the previous schemes. A conclusion was that, on balance, the evidence of impact of clinical-led commissioning was ‘limited’. 29

NHS England/Ipsos MORI, The King’s Fund and the Nuffield Trust all produced reports on CCGs in their early statutory days. 31 The King’s Fund, in conjunction with the Nuffield Trust, reported on CCGs after 1 year of operation. The King’s Fund found that less than half of GPs judged that CCGs really reflected their views; nonetheless, GPs felt that they had more influence with CCGs than they had under the PCT regime. 32 Another Nuffield Trust report noted the flaw in attempting to commission secondary care effectively without also considering primary care. 33

The Nuffield Trust team noted the progress made by CCGs in involving GP members, yet, on the other hand, noted the threats to CCGs as much of the agenda, such as STPs and Vanguards, appeared to be being driven without regard to the supposed fundamental role for CCGs. 34

In summary, studies of CCGs and their predecessor bodies tended to find that, although there was much ‘in principle’ support for the general idea of clinical leadership through commissioning, the implementation of the idea across the land (apart from a few notable pioneering exceptions) had been limited in its realisation. These reports, although providing clear descriptions of aspects of governance and engagement, paid less focused attention to actual examples of service redesign activity by CCGs and the precise work of clinical leaders – themes that we address below.

Leadership, clinical leadership and engagement

The body of literature on leadership in the English NHS, and in health services more widely, reflects the themes and concerns across many industry sectors. 35 These include the distribution of leadership within organisations; adaptive leadership; concerns about heroic charismatic leadership styles and a search for more ‘authentic’ and ethical forms of leadership; collaborative and interorganisational leadership; and whole-system leadership.

The literature on leadership in health services and on clinical leadership is extensive and we have reviewed it fully elsewhere – most notably for the NHS Leadership Academy. 36 One of the dominant themes in that body of literature is the perceived need to shift towards a compassionate mode of leadership in keeping with the caring nature of the services provided in health. 37 Another strand of literature, highly relevant to our study, is that which investigates how health-care professionals respond to policies directed towards the design of a new workforce mix in order to facilitate access and make services more affordable. 38–41 Other literature has highlighted the merits of having medics, and clinicians more generally, involved in taking up leadership positions in health services and, relatedly, in investigating the required competences. 42,43

A National Institute for Health Research-funded project on medical leadership provided data on degrees of engagement by doctors in various trusts using the Medical Engagement Scale. This project showed, as with other studies, some considerable distance between many medics and the leadership teams. 44 This work also focused on acute, specialist and mental health trusts, all of which were characterised by professional bureaucracies. As explained, our prime focus was rather different, namely to trace the extent and nature of clinical leadership using the platform afforded by the CCGs. Thus, our prime focus was on active leadership of service redesign. Often this was undertaken by informal leaders, as well as those occupying formal roles within CCGs. Attempting to lead changes in service redesign across the complex boundaries in primary and secondary care is a very different challenge.

Another central theme in the literature has been the perceived tension between, on the one hand, professional autonomy and established notions of professional practice and, on the other, the cluster of notions attached to organisational practice. Hence, the various ways in which doctors have resisted managerial attempts at organisational change and re-engineering have been extensively researched and reported in the literature. Much of this research, however, has been located in acute hospital settings where issues of competing hierarchies are at stake. As our scoping research had indicated, the more salient issues in the context of CCGs were aspects of interorganisational leadership and interprofessional leadership.

Given that the policy thrust, as seen in The wider context and the policy intent, is ostensibly towards devolved leadership, then questions are inevitably raised as to where this leadership will be located and how it will be exercised in practice. Much of the leadership work seems to get done by combinations of managers and clinicians. Indeed, sometimes managers are clinicians who hold hybrid roles. Some researchers have emphasised and illustrated the pluralistic nature of organisational leadership. 45 This refers to tendencies in many organisations for leadership to be exercised by clusters of two or three players at the top (e.g. chief executive, a chief finance officer and a chief operating officer). Extending out from this are studies which point to much wider forms of distributed leadership throughout organisations. 46–48 Informal leadership seems to be an attractive idea for some clinicians and is associated with the identity formation of leaders who practise leadership and then reflect on that practice. 49

Alternatives to top-down, planned, transformational leadership approaches have been advocated, especially in health services. These leadership approaches include the idea of mobilising action in organisations through adaptive changes and ‘adaptive leadership’;50 other related approaches include ‘appreciative inquiry’ and similar modes of action research. 51 The adaptive leadership approach makes a distinction between ‘authority’ and ‘leadership’. Instead of seeking leaders who, supposedly, know all the answers and issue these from on high, advocates such as Heifetz50 contend that leaders should be encouraged and developed who can stimulate changes in attitudes, behaviours and values. This kind of leader mobilises people to solve problems. So, leadership in these terms is ‘adaptive work’ involving many people and, through exposing and confronting internal contradictions, allowing people to find new ways of thinking and behaving. 50 Thus, in place of the heroic leader model emerges an approach which views the organisation as a system. The associated skills can be learned and tools applied to nudge the system to adapt through mobilising the efforts of multiple people. 52 This requires processual and improvisational expertise. It involves experimentation, iteration and trialling rather than linear implementation of a top-down strategy.

Storey and Holti53 found that NHS structures and culture often present numerous barriers to the effectiveness of clinical leadership for improving service co-ordination and integration from within the acute sector. Despite the barriers, they also found cases where determined doctors and other clinicians persisted in their attempts to exert positive influence on reshaping service design and delivery. 54 Other studies of the roles of clinicians and others in bringing about complex service innovations support the view that there is a need for an effective alliance between clinicians and administrative managers. Complex service innovations, such as the establishment of a region-wide network of cancer services, seem to require a multilevel and multidisciplinary array of clinical and administrative leadership roles, sometimes referred to as a ‘leadership constellation’. 55,56 This idea is reflected in the role of ‘clinical communities’. 57,58

As the above analysis indicates, there is considerable overlap between the issues researched as part of understanding leadership in health and the related domain of understanding service redesign and change in health. It is towards this last domain that we now turn our attention.

Service redesign of health and social care

Most reports of actual attempts to bring about transformative change in health care have tended to focus on the acute sector. As largely hierarchical organisations these settings have lent themselves to exploration of redesign methods derived from the business literature including, for example, business process re-engineering. 59–63 The analysis of attempts to introduce radical redesign of processes in acute hospitals reveals the complexity of such attempts and the micro-political struggles involved. 59 Consent had to be won from clinicians, and this proved to be highly conditional. 40,64–66

Professional occupational groups lay claim to ‘jurisdictions’. 66 In particular, the jurisdictional claim embraces the classification and diagnosis of a problem, the power to reason about it and to take action in relation to the identified problem. Currie et al.,40 likewise, reveal the methods used by medics to maintain existing structures, building on previous work on professional defence routines. 66,67 They found that ‘In essence, the elite actors are engaging not simply in outright “change resistance” but more subtly in institutional work designed to shape the change trajectory to ensure continued professional dominance’. It is not only clinicians who engage in institutional work when creating new forms or shoring up old ones, managers in health service redesign attempts are also heavily involved. 68

Whether or not the same kind of analysis of professional jurisdictions made in these mainly acute contexts can be transferred to the primary care setting is an open question. This is especially so in the case of CCGs, where the core institution is ostensibly a ‘membership’ organisation.

The findings from research in the acute health-care setting reflect findings and theory from the wider organisational theory literature. 69 ‘New institutional theory’ places emphasis on the shaping power of existing institutional forms on human agency and the institutional ‘work’ undertaken by actors. Institutional work is found in everyday activities, which can be seen to serve underlying purposes. To use Lawrence and Suddaby’s70 categorisation, these purposes may be to ‘create, maintain and/or disrupt institutions’. We build on the institutional work perspective in our case studies.

It is important to note that attempts at exercising clinical leadership are located within existing institutional arrangements. Clinical leadership does not operate in a vacuum. Within the context of the NHS, a great deal of institution shaping and reshaping emanates from higher-level actors, most notably NHSE and political agents; these set the direction of travel and allocate resources (financial- and legitimacy-based resources). The very origins of CCGs themselves stemmed from this source, followed by the Five Year Forward View12 and the STPs. Each of these institutional shifts was built on the assumption of the need to relocate care from hospitals to community settings. During this journey there was a move from a reliance on commissioning in a competitive market environment to large-scale planning and collaboration. Recent literature has begun to question the validity of assumptions about savings and efficiency in the shift to community care. 71 Additional challenges relate to the leadership required to implement and deliver the broad policy ideas. Our research was directed at these forms of leadership.

Studies of successful leadership of service redesign72,73 point to lessons which include distributed change leadership from both formal clinical leaders and senior managers, credible opinion leaders at the level of senior clinicians in the services concerned and ‘willing workers’ – front-line clinicians prepared to embrace the new way of working. 73

Conclusions to the literature review and implications for a research agenda

From the research reports cited above, some common threads are evident. In CCGs, as with many other membership bodies, it evidently often proves difficult to fully engage the wider membership in any meaningful way. Furthermore, these studies find that the defence of professional autonomy often competes with attempts to ‘manage’ performance across primary care. (However, our case analysis in Chapter 4 reveals some successful examples.) The body of literature also indicates that the legacy effect of past experience with practice-based commissioning and similar initiatives tended to shape perceptions and responses to new arrangements; these often leaned towards the sceptical. There remains a significant gap between the ambitious agendas for change set out in key policy papers and the reality on the ground of actions taken, to date, by most CCGs.

Key themes emerging as requiring deeper understanding include:

• the forms of influence that clinicians are actually achieving both as commissioners and providers under CCGs and associated arrangements

• how leaders (managers and clinicians) are able to use the CCG as a platform and resource to bring about service redesign and, as a key part of this, the balance between formal and informal opportunities for leadership

• the impact of these emerging forms of power and influence on the achievement of more integrated and effective forms of patient care.

Phase 1

As part of the initial scoping work, studies were made of a relatively large sample of 15 CCGs and their associated hinterlands of HWBs, LAs and health-care providers. In this phase of the project, the research team were looking both outwards from focal CCGs and inwards from the perspectives of relevant others. This included gathering views from relevant stakeholder bodies such as NHSE, CQC, the Faculty of Medical Leadership and Management, the National Association of Primary Care, commissioning support units (CSUs), the London Office of CCGs, NHS clinical commissioners, clinical senates and local medical committees, LAs, HealthWatch, community services and acute hospitals (managers and consultants). We attended many relevant conferences such as Commissioning Live and workshops at The King’s Fund. Simultaneous with the work in the first phase we undertook a major literature review. This review, uniquely, not only embraced the literature on clinical leadership and leadership studies more generally, but reached out into related relevant literatures on CCGs and other earlier forms of local commissioning, and the literatures on service redesign and change in health services.

The scoping phase was used to allow insight into the varied types of CCGs and to gain a sense of the range of practice across the country. Interviews were conducted with accountable officers, chairpersons and a representative sample of CCG office holders, including various clinical leads, locality leads, GP governing board members, lay members, nurses, secondary care doctors and patient and public representatives. Interviews were also conducted with LAs and with members of HWBs. The aim at this stage was to gain a ‘rounded view’ of CCG activity. This phase of the study also included observational studies of CCG board meetings and of HWBs. These were used to gain a sense of the scope of ambition and insight into which agents were engaged in what kinds of service redesign.

The aim at this scoping stage was to capture and catalogue the range of issues. It was also designed to gain exposure to varied contexts across the country – allowing access to issues as experienced in inner and outer London, in Northern and Midland towns and cities, and in rural areas. Research team members used a common semistructured interview guide. Interviews were recorded and transcribed in most instances, depending on the wishes of the interviewees.

Phase 2

The findings from this pilot phase were used to help construct the questionnaire for the first national survey of all 210 CCGs (following a merger the total later became 209) across England. In turn, the responses from that survey helped inform the selection of six core cases that were targeted for in-depth research over the ensuing 2 years. The findings from these cases helped inform the design of the final national survey that was conducted in the third year of the project.

Phase 3

Central to the research design were the core cases studies. Theory building from multiple cases has many recognised benefits – as well as challenges. 74,75 Case studies enable exposure to rich data in their real-world contexts. The main case study work phase was informed by the initial scoping work and also by the results of the national survey. In the main in-depth case studies, the focus was sharpened more directly onto explorations of specific examples of service redesign and an identification of who did what in conceiving, planning, resourcing and driving the changes.

Hence, at this stage, the framing of a ‘case’ tended to settle more directly on these service redesign initiatives rather than the CCGs per se. So, although our point of entry was into six CCGs, the case analyses focused on eight specific service redesign attempts. Once again we used a common semistructured interview guide (see Appendix 4). We worked in fieldwork teams of two, sometimes three, researchers and, again, interviews were recorded when feasible and helpful. Interviews were supplemented with relevant documentary analysis and with observations of board meetings, programme board meetings and other events relevant to the particular service redesign.

Phase 4

Phase 4 was the second national survey. This included many questions which had been part of the first survey and, hence, comparisons over the intervening time period (nearly 2 years) were enabled. Additionally, by the time this second survey was being designed the project team had gained extensive knowledge from the main case studies and this allowed a number of new and more refined questions to be posed. The key questions in the 2016 survey included assessments of the perceived power and influence of CCGs relative to other bodies. This was important because these assessments of the CCG as a potential lever could be expected to shape expectations of these actors about how far they could use these institutions as a basis to bring about meaningful redesign. If the institutions were judged to be relatively powerless, then that would be reasonably expected to blunt and limit would-be leaders in seeking to harness the CCG as an agent for change. If, conversely, the CCGs were judged to be influential, then that could raise expectations about what could be done by making use of these institutions.

In a related set of questions we asked about the perceived influence of other relevant bodies such as NHSE (nationally and regionally), LAs, hospitals, other major provider organisations and clinical networks, and other bodies. If these other bodies were perceived as highly influential, then this might either inhibit or curb the scope for action by the CCG or it might at least indicate the need for collaborative relationships.

Other questions were asked about the degree of engagement by the wider GP membership in the affairs of the CCG. This area of questioning was designed to assess the breadth and depth of clinical engagement and leadership. Related questions were asked about the nature and degree of influence of clinical leadership in improving and redesigning services.

Phase 5

Phase 5 included a set of international comparisons. When we had collected and analysed the data from multiple sources we wanted to gain a richer perspective by examining the findings from an international comparative perspective. Part of the reasoning was to rise above parochial issues and to reassess the meaning of the findings by comparing how health-care managers and leaders in other countries were handling similar issues, even if their circumstances were not precisely the same. We also wanted to gain deeper insights into our own data and findings by exposing them to international expert teams and entering into question and answer mode with them.

We already had relevant international connections in our wider network and so we built on that basis while also inquiring about additional experts. Our initial idea had been to hold webinars for this purpose, but initial attempts made it apparent that it was difficult to gain full attendance at synchronous events across different time zones. Hence, we adapted the method by producing synoptic accounts of our findings and e-mailing them to our network of international experts. These accounts were accompanied by a structured set of questions, including questions about how similar issues, tensions and dilemmas were handled in their own settings. This proved to be an effective and efficient approach, and it triggered a constructive dialogue which was progressed iteratively. This process of international exchange allowed us deeper and more detached perspectives on the issues and findings.

Our theoretical perspective

Next we turn to an explanation of the underlying theoretic perspective that was used in this study as a means of understanding and interpreting the processes encountered in the field and in making sense of the data.

Our underlying interpretive lens is drawn from institutional theory. As the study unfolded, it became clear that the abundant initiatives and accounts we recorded about why the organisation of health and care had to be different (or why it needed in some aspects to be stable) were replays of some basic, fundamental narratives. Actors in the field (at multiple levels) were engaging in ‘institutional work’. 70,76 This work was and is designed to maintain and justify extant arrangements, to disrupt in part or whole those arrangements and/or to create new arrangements. 70,77

The unusually active state of this institutional work in the English NHS stemmed from ongoing prevalence of multiple and diverse ‘competing logics’. 78,79 The core prevailing logics were spelled out time and time again – in CCG strategy documents; in STPs and the workshops organised to prepare these plans; in NHSE statements and documents; and in our many interviews with actors at all levels and parts of the health service. A prevalent logic was the need to ‘integrate’ services across health and social care. This was the ‘dominant creative logic’ among persons seeking to disrupt extant systems and ways of working and to install new creative modes. The dominant logic, in the sense of extant practice, was fragmented organisations offering siloed services and based on an underlying notion of the value of ‘challenge and competition’. These competing logics coexisted as layers of statute and reform were laid on top of each other, pulling system actors in different directions. It was within this context that clinical leadership was being exercised or neglected. The question arises as to what form of institutional work clinicians are engaging in: are they, as some literature suggests, mainly seeking to ‘maintain’ and defend their privileged status?40 Or might we find cases where clinicians, as intended by the policy drive which established CCGs, undertake institutional work of a creative kind, which improves services for patients at scale and which deserves to be called active and constructive clinical leadership?

Despite the phenomenon of competing logics and the institutional work involved in creating, maintaining and disrupting institutions, the existence of ‘dominant logics’ has been widely noted. 80 The attachment to, and defence of, a dominant logic does not necessarily stem from a defence of self-interest. It has been noted that embedded actors often cleave to an institutional form because it has a taken-for-granted status that engenders a deep-seated belief in the necessity of the extant system. 81

The two national surveys

Using the findings from the pilot work, we constructed the first survey instrument for distribution to all members of the governing bodies of all 209 CCGs in England. A database of 3100 individual members of governing boards was constructed by tracking board papers and CCG websites. The questionnaires (see Appendix 3) were posted to this total population using their individual names and addresses. One postal reminder was then sent to those who had not responded and in that reminder letter an online version of the questionnaire was offered.

We calculated that a response of 340 would be required for 95% confidence intervals of reasonable width. For the first survey in 2014, there were 385 responses in total (12.42% of the total population of all CCG governing board members and 79% of all CCGs). For the second survey in 2016, there were 380 responses (12.26% of the total population of individuals and 77.5% of CCGs). The 18-month interval between the two surveys was designed to allow tracking of unfolding events and the maturation of the CCGs; thus, a longitudinal element was enabled.

We analysed key features of the non-responding CCGs, but there was no discernible pattern. They were distributed geographically and we could find no particular characteristic common features among the non-respondents that would distinguish them from those who did respond. In case of bias towards high-achieving CCGs, we compared our respondent CCGs with the profile of the 2016 NHSE ratings of CCGs. The resulting comparison is shown in Table 1.

The very close match suggests that respondents from struggling CCGs were just as willing to respond to the survey as those from high-performing CCGs.

The main in-depth case studies

Following the pilot case study phase and the first national survey, the focus of research work shifted to the six main case studies. The selection of these core cases was informed, as planned, by the results from the first national survey and was also shaped by our knowledge of activity across potential case sites. We wanted geographical coverage so we ensured that the cases included CCGs in London, the Midlands and the North, and we also ensured coverage of urban and rural settings. Of special importance was our knowledge of the degree of service redesign activity occurring in these settings. A random selection of cases might easily have resulted in six CCGs characterised by relatively little activity. In order for us to be able to tease out the elemental processes of clinical engagement and leadership in service redesign, it was important to ensure that some of the cases had strong prima facie indications that they would be able to offer opportunities for detailed study of substantial activity, but we avoided over-reliance on the feted cases that may have enjoyed unusual and exceptional support.

Within each CCG we selected for detailed study one, or in some cases two, specific service innovations in particular areas. These focused on care of the frail elderly (usually involving cross-boundary working designed to ‘integrate’ health and social care); innovations in urgent care (usually involving cross-boundary working with GPs, acute hospitals, the ambulance service and paramedics); and/or mental health.

Within these cases there were also many research choices to be made. We used both purposeful sampling and theoretical sampling to access the most appropriate informants.

Guidelines from Lincoln and Guba82 were followed regarding ‘purposeful sampling when selecting informants within the case studies’. First, we selected informants whom we expected would have the most relevant knowledge of the background issues affecting the CCG as a whole. This cluster was broadly common across the cases (accountable officer, CCG chairperson, clinical leads, and so on). However, in addition we were sensitive to the particularities of each service redesign attempt studied. Here we used onward referral – a snowball research technique – in order to include informed and diverse perspectives appropriate to the situation. For each service redesign attempt researched, a set of interviewees was agreed with a senior sponsor of the research collaboration within the CCG. The selection of each sample was guided by the need to include the actors who had played a key role in initiating, shaping and evaluating the course of the service redesign event. This typically meant that clinical leads, programme managers and project managers, as well as some of the clinicians, were involved. In several cases we were also able to include patient representatives who had been involved in the service innovation (e.g. through sitting on the relevant programme board). In recognition of the multilayered nature of health-care reform, it was necessary to look upwards and outwards to the wider context, including area, regional and national policies and institutions which had an impact on the service areas under focal scrutiny. Thus the institutional settings usually had fuzzy boundaries which extended across primary, secondary, administrative, regulatory, professional and educational institutions.

Theoretical sampling allows the clarification of the relationships among multiple constructs. 75 It allows the revelation of unusual phenomena of diverse kinds. We used this approach in order to identify further interviewees in each case, to ensure exposure to data from informants who could add to an accumulative and iterative body of knowledge about relevant issues. The range of informants evolved with the emergent theory. Themes were pursued until little additional insight (what has been termed ‘theoretical saturation’) was gained. 83

We used three main methods within the cases. First, we conducted pre-entry documentary analysis drawing on a wide range of sources. Second, we conducted face-to-face semistructured interviews. Third, we used non-participant observation. Although interviews can be a highly efficient and effective research tool, it is recognised that they also present the challenge that bias may arise because of the efforts of image-conscious informants. This challenge was mitigated through the use of multiple interviews among diverse informants who were likely to view the issues and events from different standpoints. 84

The mode of operation was for each case study to be conducted by two members of the research team, with one of them acting as the lead investigator and contact person for that site. Some of the interviews were conducted with both researchers present, other interviews with just one researcher. In the main, interviews were recorded and transcribed. The researchers drew on a semistandard interview schedule comprising semistructured interview questions. These had to be adapted to the varying situations including, for example, the subject of the service redesign under scrutiny and the role and vantage point of the interviewee. The semistructured interview schedule was adapted accordingly. Appendix 4 shows a typical example of one such interview guideline.

Case study data analysis

As mentioned, members of the research team worked in pairs for each main case study. These subteams undertook the first stage of each data analysis process. Following Miles et al. ,84 these first-level analyses were constructed by careful reading of each individual transcript and the development of codes for exploring, describing and ordering the data for an entire case. In this way a coherent narrative of the flow of events within each case could be constructed. This was combined with a descriptive account of the issues and challenges encountered by the actors involved. These first-level reports used a common framework: (1) context, (2) focus and narrative of the case, (3) clinical leadership themes emerging and (4) emerging ideas for cross-case comparisons. The first three sections of these initial draft reports were fed back to informants in the case studies concerned, as a way of validating the accuracy of the data collected and the descriptive interpretations made.

Next, the first-level case reports were discussed, in turn, at a monthly series of research team meetings. From these discussions emerged ideas for explanatory concepts that could be applied to understand differences and similarities in the nature of clinical leadership across the cases. This process of discussion, conceptualisation and comparison between the cases led to the development of the conceptual framework for analysing the cases set out at the beginning of Chapter 4. Once again, following guidelines from Miles et al. ,84 this conceptual framework was then used to develop explanatory codes for a second level of analysis of interview, observational and documentary data in each of the cases (Table 2). This second-level analysis was carried out by two members of the research team, who were also the main authors of this report. That analysis brings together the descriptive summary of events with an explanatory analysis of the forms of clinical leadership and their relationship to the achievements and difficulties encountered in bringing about service innovation. The analyses are compared and discussed further in Chapter 5.

Survey analysis

Results from the two national surveys were analysed in three main ways. First, the responses to each of the questions were gathered together and the results presented as tables and charts. Second, a number of cross-tabulations were made in order to investigate whether or not occupants of different roles answered questions in particular ways. Third, comparisons were made between our data and the ratings of CCGs made separately by NHSE. These correlations produced some very interesting findings.

A notable feature of the completed questionnaires were the free-form questions. These elicited fulsome, useful responses. As a result of the careful preparation of the questionnaires in conjunction with a range of informants from the scoping phase, respondents readily recognised the relevance of the issues being raised and were very keen to share their thoughts. In the next chapter, the statistical results stemming from the structured questions are presented and analysed along with the free-text responses.

Public and patient involvement

We sought to involve the public and patients as far as was feasible, relevant and practicable at all stages. In the first instance, a nationally renowned patient and public involvement (PPI) representative with very extensive experience of PPI was appointed as co-chairperson of the Project Steering Committee. This representative was involved in all aspects of the research from the initial design, the oversight of research instrument construction and the review of findings at all stages, to the discussions about the dissemination of findings. During the course of the project, PPI was used mainly in relation to the specific service redesign initiatives that were the focal component of this study. These initiatives often had PPI arrangements in place and we tapped into these rather than seek to set-up new arrangements. One extension of this approach was that a member of the project team sought permission to become an active participant member of a PPI group that was associated with one of the service redesign initiatives in the core case studies. Full ethics approval from the Research Ethics Committee overseeing the project was sought and full disclosure was made to members of the PPI group. Another dimension was that in the surveys and the case studies we took steps to find out how patients and the public had been involved in the redesign of services.

Introduction

In order to gain a broad view of the state of play across all CCGs, a national survey was designed and administered in 2014 and again in 2016. The populations targeted were the members of the governing boards of all CCGs. This included chairpersons, accountable officers, finance directors, GP members (often these were clinical leads of particular service areas), other clinicians such as nurses and the secondary care doctor representatives, directors of public health and lay members.

The first survey gleaned 385 usable responses and these represented 12.42% of the total population of all CCG governing board members and 79% of all CCGs. For the second survey there were 380 responses, which represented 12.26% of the total population and 77.5% of all CCGs. The 18- to 19-month interval between the two surveys was designed to allow tracking of unfolding events in a time series and the possible maturation (or decline) of the CCGs.

The questionnaires in both phases contained many shared themes, but the 2016 questionnaire included additional questions which were derived from the case study work that had taken place during the intervening period. Patterns of responses were also correlated with a separate data set: the ratings allocated to CCGs by NHSE for 2015/16. In comparing our survey results with the NHSE data, we used the headline rating. We considered using the component ratings that were most relevant to our study (i.e. ‘Well-led’; ‘Finance and Planning’). However, we found such high correlations between these components and the headline rating that, in practice, the headline rating proved to be sufficient.

A number of core issues were investigated in both phases. The first of these was the respondents’ perceptions of the autonomy and influence of CCGs as institutions. This was assessed relative to other bodies such as NHSE, NHS Improvement and the CQC. In other words, the initial objective was to understand how important and influential the CCGs were in the wider scheme of the NHS. A second continuing theme was the relative influence of clinicians – most especially GPs – within the CCGs. This aspect was central to the project aim: do the CCGs in practice provide a platform for the meaningful exercise of clinical leadership? A third core question area was an examination of the nature of the contribution made by clinical leaders. Other more subsidiary questions covered in both surveys were: the degree of wider GP engagement; training and development offered to GP members of CCG boards; conflicts of interest; and assessments about the future role of CCGs.

The questionnaire was a combination of structured questions and a set of more open-ended questions with space for free-form answers. There was a very high response to the free-form questions – with 96% of respondents taking time to write in these sections. This was a strong indication of the extent to which respondents were engaged with the questionnaire and found it relevant and interesting. The respondents were keen to express their views and many did so with passion.

Copies of the questionnaire can be found in Appendix 3.

The profile of respondents

As can be seen from Figure 1, responses were received from all role categories with the numbers broadly reflecting the relative numbers sitting in these boards. Hence, GPs were the largest group of respondents.

FIGURE 1.

Roles of respondents.

The first thematic question examined was the perceived influence of CCGs. We wanted to understand what respondents thought was the scope to make a difference through these institutions.

Perceived influence of Clinical Commissioning Groups

The first main substantive question asked about the perceived influence of CCGs relative to other NHS organisations. The reason for asking about this was that the overall research question was essentially about the scope for leadership influence using CCGs as an institutional platform.

We asked board members to make a comparison of the perceived influence of their CCG relative to other bodies such as NHSE and NHS trusts. The form of the question asked for a rank ordering of the bodies most influential in shaping local health services. Figure 2 shows the results. Half of the respondents judged that their CCG was the most influential in this regard, and NHSE was ranked second. However, nearly half of the respondents did not rate their own CCG as the most influential. In the 2016 survey, some respondents under ‘other’ noted that Vanguards and STPs were emerging as influential in shaping local services.

FIGURE 2.

The relative influence of different institutions (2016).

It is clear from Figure 2 that ‘my CCG’ was seen as carrying the most influence. NHSE was seen as the next most influential institution in shaping service redesign and the growing importance of collaboration between CCGs is also indicated. However, the fact that nearly half of CCG board members themselves judged that their CCG did not exercise the most influence might be expected to be a potential curb on expectations about the exercise of leadership by CCG clinicians or other CCG players.

Would different role occupants have similar views? The data for the assessment of influence split by role holder are shown in Figure 3.

FIGURE 3.

Relative influence of different bodies as reported by different role holders.

Notably, it was the chairpersons of CCGs who were most likely to perceive their CCGs as influential. However, other role holders, most notably finance directors, did not. Less than half of accountable officers perceived their CCG to be the most influential body in shaping services. This is an especially important finding because arguably, among all of the different role holders, one would expect the accountable officers to have the clearest line of sight on the various forces at play. It would suggest that the reality of CCG influence is rather less than was implied by the policy intent as it was described at the outset of this report.

Many GPs on CCG boards reported that they were disillusioned with their CCG experience. For example:

The CCG is becoming increasingly bureaucratic and much more like a PCT. We are increasingly subject to government directives and with short deadlines. There is no space for creative solutions from the CCG. I am angry and sad at the current state of CCGs.

GP member of governing body

We then undertook a different analysis: the perceived relative influence of different bodies was correlated with the ratings of CCGs allocated by NHSE. The results are shown in Figure 4.

FIGURE 4.

The relative influence of different bodies (2016) by NHSE headline rating of the CCG.

The notable finding is that respondents from CCGs rated as ‘inadequate’ were far less likely to rate their CCG as having influence. In contrast, respondents from CCGs rated as ‘outstanding’ were much more likely to perceive their CCG as influential. It may be that the pattern of institutional influence is reflected in performance. Alternatively, it may be that this pattern suggests the possibility of a self-fulfilling prophesy: those expecting low impact achieved just such; conversely, those assuming that they had influence were able to exercise it. There is an alternative explanation: the low and high performers sensed the state of play and disowned or owned responsibility accordingly.

Figure 5 shows comparative data for 2014/16 with regard to perceived influence on the design of services in the local health economy. (Respondents were asked to assign a percentage rating across the institutions listed, adding up to 100%.) The pattern remained fairly stable over the 2 years. ‘My CCG’ was seen as the most influential body, but there was a slight fall-off in this assessment in 2016. There certainly seemed to be no sense of a growing influence.

FIGURE 5.

Institutions influencing service redesign.

The largest group of respondents said that their own CCG was the major player (38% of influence in 2016). However, other bodies were also seen as important, and these included NHSE (14%) and local collaborations of CCGs (18%). There were significant differences in this assessment depending on the role of the respondent with regard to their views about NHSE and NHS Improvement. GP members of the governing bodies were most likely to perceive NHSE and NHS Improvement as influential.

Next we looked at ratings of CCGs by perceived importance of collaboration among neighbouring CCGs. The results are shown in Figure 6.

FIGURE 6.

Rating of influence of a ‘collaboration of local CCGs’ by NHSE headline rating of CCG.

These results suggest that those respondents whose CCG was rated ‘good’ were those seeing collaboration with other CCGs as important, whereas those rated ‘inadequate’ tended to see it as less important. On the other hand, the ‘outstanding’ ones were seemingly able to be self-reliant. And perhaps they did not want to collaborate with others in case this affected their performance ratings. When asked to rate the influence exerted by hospitals and other providers, it tended to be respondents from CCGs rated as inadequate who were more likely to accord the highest influence to these bodies (Figure 7). This may reflect the reality of powerful local hospital trusts or it might reflect a lack of will or capability in tackling these providers.

FIGURE 7.

Rating of influence of ‘hospitals and other providers’ by headline rating of CCG.

The next section shifts focus from the influence of CGGs to an analysis of relative influence within them. Most especially, there was the contentious issue of whether managers or clinicians were exercising power and, relatedly, what influence, if any, other role holders such as the lay members, the secondary care doctors and the nurses had.

Influence within Clinical Commissioning Groups

Given that the policy intent, as shown in Chapter 1, was to create commissioning organisations led by clinicians – and most especially by GPs – we wanted to know whether or not these institutions had lived up to that aspiration. We began with a question which asked about the relative influence of different groups on the redesign of services. The four groups were managers, GPs, other clinicians excluding GPs and lay members. The results are shown in Figure 8.

FIGURE 8.

Influence of managers, GPs, other clinicians and lay members in the redesign of services.

In broad terms, managers and GPs were seen to be the most influential by far. In 2014, of the two, GPs were marginally ahead; however, by 2016 the rankings had reversed and managers were marginally ahead in terms of ranked influence. This is especially notable given that the majority of respondents were GPs. Other members of the governing bodies (including the lay members, secondary care doctors and nurses) were rated as far less influential.

Some answers from 2016 were then broken down to show how different kinds of respondents answered this question. The results are shown in Figures 9 and 10.

FIGURE 9.

Influence of managers, as reported by different role holders (2016).

FIGURE 10.

Influence of GPs as reported by different role holders (2016).

It was evident that finance officers tended to see managers as the most influential figures. GP members of governing boards and others (directors of public health and other managers) tended likewise to see managers as influential.

Next, we delved deeper into the perceived influence of GPs, as broken down by role of respondent. As the results in Figure 10 show, GP members of the boards were, ironically, the least convinced that they had much influence. It may be that other board members wished to maintain the official image of ‘GPs in charge’. Accountable officers, for example, may have wished to reflect the idea that they were the servants of a membership organisation.

We also wanted to know in what capacity GPs were acting when they influenced service redesign. Was it as official governing members, as clinical leads who did not have a seat on the governing body, as locality leads, or as leaders of GP federations? Figure 11 shows the results for both 2014 and 2016.

FIGURE 11.

Roles of GPs shaping service redesign (2014 and 2016 compared).

Perhaps not a surprise, given the role of many respondents, GPs sitting on the governing bodies were seen as the most influential of the GP categories. Of note also was that the perceived influence of locality-level commissioning GPs declined between 2014 and 2016.

A related question concerned who sets the compelling vision. Were GPs and other clinicians making a leadership contribution through envisaging alternative service provision or was this vital leadership role filled by others? Figure 12 shows the results.

FIGURE 12.

Who sets the compelling vision for service redesign?

In 2014, the results for clinicians were the same (between 25% and 26% of respondents said that GPs set the compelling vision). The main difference between the two time periods was in the proportion of respondents who answered ‘neither’ to this question: 23% in 2014 but a mere 2% in 2016. At this later date the most common answer to the question ‘who sets the compelling vision?’ became ‘both equally’.

Figure 13 shows the breakdown by role of respondent to this same question. This shows that the nurses and accountable officers were most likely to say it was both equally, whereas more ‘independent’ observers (finance officers, secondary care doctors and laypersons) were more likely to name managers as key players in this regard. (Accountable officers once again played down their role.) No role group said that GPs were the ones mainly setting the compelling vision.

FIGURE 13.

Vision answers as reported by different role holders.

As shown in Figures 12 and 13, most respondents suggested that it was managers and clinicians equally who set out the compelling vision. These results suggest that the notion that GPs would be the visionaries and architects and that managers would play the role of delivery agents is not an accurate depiction of the reality in most cases. There is also more evidence here of dual leadership occurring – a particular type of distributed leadership.

We asked about communication with patients and the public, and the results are shown in Figure 14. For these stakeholders, managers acting alone or acting equally with clinicians account for 87.5% of this kind of communication. In their free-form answers, some respondents suggested that the role was mainly undertaken by managers, although clinicians might be ‘rolled out’ if some serious change was being proposed. Once again there was apparent progress between 2014 and 2016. In 2014, nearly one-quarter of respondents said that neither managers nor clinicians from the CCG were in communication with patients and the public, but in 2016 this fell to only 2%.

FIGURE 14.

Communication with patients and the public.

In a related question, we asked who provided the insights into public and patient needs. The results (shown in Figure 15) suggest that the largest part of this is done jointly with managers and clinicians, although 21% of respondents said that managers were mainly responsible for this activity.

FIGURE 15.

Who provides insight into patient needs?

The main difference revealed in Figure 16 is that respondents from CCGs rated as ‘inadequate’ were most likely to say that managers provided most expert insight into patient and public need, and they tended to regard clinicians as less active in this regard.

FIGURE 16.

Who provides insights into patient needs? by headline rating of CCG

An increasingly important theme since the formation of CCGs as independent statutory bodies has been the growth of the idea that more collaboration is required – with other CCGs and with other stakeholders, such as social services and voluntary bodies. We asked about this next.

Building collaborations

The building of collaborations with providers and with other commissioners has increasingly become a vital activity for CCGs. Who would undertake this vital work? Figure 17 shows the results.

FIGURE 17.

Collaboration building.

The results suggest that half the respondents saw managers and clinicians equally involved in this. However, a very significant proportion (43%) identified managers as leading on this, and only a very small proportion (5%) argued that clinicians led on this work.

Qualitative, free-form answers added some depth and flavour to the question of the kind of contribution being made by clinical leaders.

A central reason for much of the emphasis on clinical leadership, as we noted in the literature review, relates to the idea that clinicians have the potential to make a difference through a distinctive set of contributions. We asked for free-form response answers to the question ‘What distinctive contributions do clinicians make when clinical leadership works well?‘.

The answers clustered into eight main categories of types of response, as shown in the first column of Table 3. Text in the second column is verbatim responses. Fuller tables are shown in Appendix 6.

Although the form of the question asked for identification of the kinds of positive contributions that clinical leaders make, some respondents nonetheless used the space to express more critical views, such as ‘I’m not sure they do’.

As these reservations stem from governing board members with a close-up view of proceedings in CCGs, it is especially interesting to note the scepticism about the impact of clinical leadership.

These kinds of critical comments take us next to the question we asked about the ‘major obstacles to achieving clinical leadership in service redesign’.

Obstacles to achieving clinical leadership

This free-form question elicited many responses. The most commonly cited response was that GPs did not have the time to fulfil the role adequately. More than 92% of respondents gave this response. Respondents also took the opportunity to use this question to identify what they saw as the source of the failings and difficulties faced by CCGs. Hence, many GP respondents pointed to wider problems of the health service at large (such as fragmentation, complexity, political interference, bias towards the acute sector and the like). Some managerial respondents used the question to highlight shortcomings in the GP contribution (poor attendance, lack of system-wide understanding), whereas some GPs also pointed to managerial shortcomings. Answers are categorised in Figure 18.

FIGURE 18.

The main obstacles to clinical leadership in CCGs.

All types of respondents were ready to say that ‘lack of time’ was a major issue, but beyond that divisions opened up, with some managers suggesting that GPs lack the will and commitment to even want to devote time to CCG work and that there were shortcomings in capability.

Some GP respondents argued that the sources of the problem were deeper – that they extend to intractable system problems, such as fundamental diversity of objectives and lack of autonomy for the CCGs to influence the system because of the power and influence of bodies (such as NHSE, NHS Improvement) and the power of the acute hospitals – all of which impeded the plans of the CCGs. In other words, there was evidence of a perceived vicious circle. Yes, many GPs were reluctant to step forward to commit significant time and energy to the work of the CCGs, but they contended that this was because there was little incentive to do so, and indeed little point in so doing because bigger forces are stacked against this being a rational action. These perceptions led to a paradox of disengagement. This is shown in Figure 19.

FIGURE 19.

The vicious circle of lack of clinical engagement and leadership.

This paradox was a vicious circle which was mutually reinforcing. Talented, energetic, potential leaders were reluctant to step into active roles as leaders of service redesign on CCGs. Other system players, including managers and influential bodies (such as NHSE and NHS Improvement) judged that the problems facing the service were so large and urgent that they themselves needed to step in. This, in turn, further confirmed the suspicions of GPs and gave justification for limiting the amount of engagement; the one ramped up the perceived justification for the other. Further details can be found in Appendix 6.

We sought to gain an overall assessment of the influence of clinical leadership. Implicit in such a question could be perceived impact as well as an assessment of behaviour patterns on the governing bodies. The results are shown in Figure 20.

FIGURE 20.

Overall influence of clinical leadership.

The results told an optimistic story. In both 2014 and 2016 the majority (68% in 2014 and 60% in 2016) of respondents leaned decisively towards the positive end of the spectrum; that is, they said that clinical leaders were central to all, or nearly all, redesign initiatives or to a significant proportion of these initiatives. This, in broad terms, might be seen as an overall endorsement of the idea of CCGs. The fall from 68% to 60% in just 2 years might, however, be seen as a matter of concern given the central nature of this question.

We dug deeper into this by disaggregating by role of respondent (Figure 21) and by the NHSE headline rating of the respondent’s CCG (Figure 22).

FIGURE 21.

Overall influence of clinical leadership as reported by different role holders.

FIGURE 22.

Overall influence of clinical leadership by headline rating of CCG.

Significant differences were found. Most notably, finance officers tended to place much less importance on clinical leadership than did other role holders. GP members of governing bodies and managers (other than accountable officers) were also more circumspect about the role of clinical leaders in service redesign. The chairpersons and accountable officers on the other hand report that clinical leaders are central to nearly all design initiatives or at least involved in a significant proportion of initiatives.

As Figure 22 shows, respondents in CCGs rated as inadequate were the least likely to say that clinical leadership was significant in improving or redesigning services; and respondents from good and outstanding CCGs were most likely to say clinical leadership was central or influential in a significant proportion of initiatives. On the face of it, these findings are highly suggestive of the importance of the role of clinical leadership.

Examples of positive impacts by the Clinical Commissioning Groups

In the pilot phase in 2014 we had been somewhat surprised to hear the response from accountable officers and chairpersons that the main achievements had been to establish the CCGs and make appointments. In other words, they focused on process aspects and institution building. So, although at that time they were relatively new bodies, they had been in existence for around 2 years in statutory and shadow form and we were expecting to see some more substantial claims about new initiatives and their progress. Therefore, by the time of the survey in 2016, we expected to hear much more about meaningful impacts and service improvements.

The question was an open invitation to showcase the ‘best’, the most impressive impacts made by their CCGs. How did they measure up?

The resulting picture was very mixed. Some respondents struggled to cite any examples of significant impacts made by their CCG. Indeed, given that respondents were all serving members of CCG governing bodies, it was perhaps surprising to hear reports saying that there were ‘none’ (no impacts to report), ‘nil’ or ‘still waiting!’ However, these were not typical. Most respondents were able to list a few impacts, albeit often the claimed initiatives were in the early stages. For example, ‘We are designing a blueprint for primary care’, ‘Some service design’, ‘Raising awareness’, ‘Commissioning a local scan service’ and ‘Influencing the end-of-life care’. Others claim significant outcome-based impacts.

Most common were the modest claims, ‘Implementation of referral support website to improve communication and dissemination of projects and services to clinicians’.

Others were at an early stage and rather vague: ‘Plans for future changes to acute and primary care in a joined-up way’, ‘Bringing the future of primary care to the front of the agenda’ and ‘Looking at better working together with providers’.

The claimed impacts ranged across primary, secondary and community services. Judging by the number of ‘mentions’, CCG service redesign has been rather more directed at primary and community services than at secondary care. Notably, there was very little reference to the use of commissioning and decommissioning as tools for bringing about change. Another notable point is that impact is often perceived in process-improvement terms – such as building positive working relationships, engaging stakeholders and stimulating discussions.

As predicted by institutional theory, there appeared to be considerable evidence of imitation. CCGs form a loose community of practice, they have learned a common language, and their ambitions are, in part at least, formed by the wider institutional field. Hence, at a general level, there were very frequent mentions of ‘a shift of resources from acute to primary and secondary’; ‘bringing care closer to home’; and ‘reducing hospital admissions’. Other comments were responses to national initiatives: use of the Better Care Fund (BCF); co-commissioning. Conversely, some referred to initiatives being stopped by NHSE.

A straightforward frequency count of the most-mentioned impacts resulted in the following list of 10 in ranking order:

1. musculoskeletal service (MSK) moved from acute to community settings

2. mental health focus [e.g. Improving Access to Psychological Therapies (IAPT) self-referral]

3. improvements to frail elderly care and reduced emergency admissions

4. GP out of hours; federations and practice collaborations

5. urgent care and front door of accident and emergency (A&E)

6. redesign of rehabilitation/discharge

7. integrated care initiatives

8. implementation of a community-focused paediatric acute response team

9. stroke services improvement

10. redesign of community services.

Mentioned less frequently were any significant impacts on secondary care or much deployment of the power of commissioning and decommissioning. Indeed, it was also notable and curious that, given all of the talk about prime contractor arrangements and outcome-based commissioning, there was no mention of these in response to the question about the main impact of the CCG to date, or at least not directly. These forms of contracting were implicit in some of the responses about MSK and to a lesser extent in relation to changes in services for the frail elderly, but still there was no explicit mention. It might be suggested that this is because, even where arrangements had been made, it was rather too early to measure actual impact in terms of outcomes. However, that had not been a factor in many of the other responses, which were free in their references to ‘developing’ and ‘moving towards’. Fortunately, we had a specific question on prime contracting and outcomes-based commissioning. Despite the fact that, when asked the open question about ‘the difference made’ by their CCG, almost no one volunteered a reference to forging prime contractor arrangements or helping to design outcome-based commissioning and yet when asked directly about the importance of these, the majority of respondents (70%) said that they were ‘very important’. Indeed, many said that they were ‘vital’ and ‘absolutely necessary’.

Assessment of service redesign progress

The preliminary pilot work had alerted us to the need to distinguish between broad plans and actual activity. Hence, in the survey we asked a question which sought to tease out participants’ own assessments of impact. They were asked to respond to the statement ‘Plans for service redesign have far exceeded tangible changes to services’. Figure 23 shows the results.

FIGURE 23.

Plans vs. tangible achievements (1 = low agreement, 5 = high agreement).

Figure 23 shows that, even among those serving on boards, there is a widespread acceptance that their plans for service redesign ‘far exceeded’ what has been achieved in practice.

When participants were asked if ‘CCG achievements have more than matched expectations’, there was a very clear pattern. Respondents from CCGs rated as ‘outstanding’ agreed most strongly, whereas those from CCGs rated as ‘inadequate’ tended to report that achievements had not matched expectations. This might be as predicted. However, it does seem to indicate that CCG office holders had a pretty good sense of how well their organisations were performing.

Summary and conclusions

The two national surveys offered an opportunity to gain some overall impressions of these actors’ insights and assessments of some basic questions. The surveys revealed a mixed picture. There was evidence to support an optimistic view of the worth and importance of CCGs and of the role of clinical leaders, but there was also some evidence to support a more pessimistic view.

Indicators underpinning an optimistic assessment included the evidence that the majority of respondents said that ‘my CCG’ exercised more influence than the other bodies that were active in the area. Likewise, within CCGs, there were indicators of the influence exercised by GPs. They were assessed as broadly as influential as managers. Other data pointing towards an optimistic view can be found in assessments of who sets the compelling vision – a significant indicative role in the context of these bodies. The majority of respondents said it was set ‘equally by managers and clinicians’ and, among those who answered differently, clinicians were more likely than managers to be named as the vision setters. Moreover, this pattern represented a maturation of CCGs since 2014: the ‘both equally’ assessment increased from 33% to 54%. Trends in communication with secondary care clinicians and with patients and the public also offered grounds for optimism. The overall assessment of the influence of clinical leadership was that they were central to nearly all service redesigns (35%) or in a significant proportion of redesigns (25%). Taken together, this suggested that around 60% of respondents claimed a key role for clinical leadership in practice.

Positive assessments of CCG influence were more often made by chairpersons and accountable officers (i.e office holders whom one might well expect would champion CCGs and indeed remain optimistic about these institutions even in the face of challenges). In contrast, finance officers and GP board members were much less inclined to offer a positive assessment. Similarly, GPs on governing boards tended to be the least convinced that GPs were influential in the redesign of services. Moreover, GP respondents reported that practice workloads were impeding engagement with clinical leadership and that, as a result, engagement with CCGs was declining. One might expect that at least GPs on the CCG board would be the prime intermediaries and communicators with other primary care clinicians, but only 40% of CCG managers made this assessment, they suggested it was done either by managers or jointly with clinicians. In addition, as collaboration (with other commissioners and with providers) has become a bigger theme in recent years, one might look to the skills of clinicians in this regard. However, the data indicated that managers were felt to be more active in this – either on their own (43%) or conjointly with clinicians (51%) – but with only 5% saying that clinicians were the main builders of collaborations. On the overall assessment of the influence of clinical leadership on service redesign, this reduced somewhat (though not statistically significantly so) between 2014 and 2016. When asked if the plans for service redesign had ‘far exceeded’ tangible change, the majority (55%) agreed that they had.

Of note was that, although respondents many were highly doubtful about the future survival of CCGs, the majority expressed their strong conviction that commissioning and related devices, such as outcome-based commissioning, were approaches worth preserving. This finding might reflect the general orientation of those persons attracted to the work of the CCGs.

To gain further insight into the actual work of clinicians in service redesign using the CCG as a potential platform for action, it was necessary to delve deeper. For this purpose we used a case study methodology. We report on the results of the case study work in the next chapter.

The analytical framework

Drawing on the findings from the 15 scoping CCGs in phase 1 and the findings from the two national surveys, we were aware that clinical leadership in service redesign was being enacted in different arenas. By ‘arenas’ we refer to the settings and domains where leadership is exercised. 85 This may be a physical space (such as a board room), but just as often it will be a social space (such as different communities of practice). These arenas may be temporary and sporadic or relatively stable. Crucially, in a health service context where there are multiple overlapping organisations and professional groups that periodically come together or are brought together, the arena is a realm of interaction. In the kinds of health service redesign attempts we were investigating, influence extended in varying degrees across organisational boundaries, across formal lines of authority and across looser informal groupings. Indeed, as CCGs are decidedly not conventional hierarchical organisations, exercising ‘leadership’ in and around them is of a very different order to that found in an organisation, such as an acute hospital or a public limited company.

In and around CCGs it appears that clinical leadership was located in each of our eight case studies in three main types of arena. One of these arenas was at the strategic, policy-making level, typically located at the CCG governing body, but sometimes also involving other strategic bodies above this level. A second was found in the setting of programme boards and similar bodies responsible within a CCG for the operational commissioning of particular groups of services. A third was in the delivery setting, where clinicians involved in providing innovative services worked on the operational and practice aspects. Figure 24 displays these types of arenas in a schematic way.

FIGURE 24.

Three arenas of clinical leadership.

The depiction of three different kinds of arena as points of a triangle containing clinical leadership is intended to convey a richer understanding, beyond the idea that there is a hierarchy of clinical inputs corresponding to a hierarchy of NHS authority. Our cases demonstrate that clinical leadership is needed in each of these arenas, but that the system works in an interdependent way. The relationships between the arenas are constructed through a mix of collegial, professional network mechanisms and market relationships, as well as, indeed rather more than, through hierarchical command and control relationships.

The first arena for the potential exercise of clinical leadership (point 1 of the triangle in Figure 24) was concerned with the development of service priorities for the whole population living within a defined geography and with the strategic approach to meeting these priorities. In the original conception of CCGs, this strategic arena was the governing body of a CCG. This is where GPs and others were originally meant to be making a difference. They were to be allocated a budget to meet the needs of a population and expected to proceed with the whole commissioning cycle, including assessing need, reviewing service provision, deciding priorities, designing services, shaping the structure of supply, planning capacity and managing demand, managing performance and seeking public views. This cycle of activity was supposed to be ongoing. From the cases studies we found that practice was rarely quite so systematic. Opportunistic funding and, in some cases, financially straitened circumstances intervened.

We found that, in three of our eight cases, tasks in this strategic arena were undertaken by clusters of neighbouring CCGs acting in concert. In one case this was a collaboration between all CCGs active within a county-wide footprint. In another case the strategic work to redesign integrated services for the elderly and those with more severe long-term conditions was done at the level of a collaboration of four neighbouring CCGs working together with their LAs. Yet, in a third case the dominant strategic arena was a collaboration between the CCG and a coterminous LA. In all cases there was a drift towards, and pressure towards, shifting some strategic issues to a higher level, such as strategic reference groups and STPs.

Across all eight cases, we were able to track instances of the nature of clinical leadership within this kind of strategic arena. The normal key focus in these arenas was putting ‘the clinical case’ for major service development initiatives, such as an integrated care initiative or a primary care development initiative. Strategic clinical inputs of this nature can be seen as paving the way for further and rather different modes of clinical leadership needed to produce service redesign, in the second and third kinds of arena. At the same time, we found that this strategic level of commissioning leadership was perhaps less emphatically provided by clinicians than might have been expected from the original aspirations attached to CCGs. Professional managers, with support from CSUs, were likely to be attempting at least some of this.

The second arena (point 2 on the triangle) allowed the exercise of clinical leadership in the matters of operational commissioning. The cases showed that much of this work took place within ‘programme boards’. These bodies were allocated the responsibility for progressing tranches of work by the CCG, each typically concerning delivering services addressing broad categories of health need, such as mental health, urgent care, or care for the frail and elderly. The programme boards sought to bring together key stakeholders. Their remit was to review current provision and identify problems and gaps in that provision, to shape initiatives, develop detailed policies, recommended contracts and monitor performance. In the cases we followed, there was evidence of work within the tradition of collaborative supply chain activity; provider clinicians as well as GP commissioning leads for the area concerned were represented on these boards and were in a position to bring to the table both the legitimate concerns about viability being experienced by providers and ideas for how to deliver services more cost-effectively. Collaborative, clinically informed discussions about the best way of meeting needs could then provide the basis for formal contracts between the CCG and provider organisations, which the programme board would then monitor and manage.

The third arena (point 3 on the triangle) is where we found clinical leaders, usually based in provider organisations, engaging in what might be termed ‘implementation leadership’. It is also where we found much of the PPI taking place. The implementation and practice arena is hugely important because grand plans would count for little if GPs, community and acute clinicians failed to respond to and enact the new ways of working called for by their colleagues in commissioning roles. Indeed, all of our cases in some way illustrate that this work at the sharp end was where most work needed to be accomplished. In practice, the exercise of clinical leadership in this arena of delivery went well beyond ‘mere’ implementation of a new service specification. Although individual provider clinicians had key roles in fleshing out the detailed clinical practices, our cases also revealed the importance of new collaborative forums for working out operational detail in integrated services. We found fascinating examples of learning occurring between different acute providers. We also saw the creation of practice networks in primary care, where learning was shared between practices about how to improve services and standards. Peer pressure, peer-to-peer role modelling, the development of a shared moral ethos and mutual learning were all vital, especially in such instances. In some cases, this arena of service delivery leadership extended beyond primary and acute health service providers and took in additional service providers, such as adult social care, housing and employment support.

An essential point of Figure 24 is that clinical leadership is exercised in different arenas and depends on different capabilities. Clinical expertise and experience had important distinctive roles to play in each arena. However, there were also crucial interconnections, grounded in the nature of clinical expertise and experience. Clinical perspectives served as an important integrative mechanism. Clinicians with knowledge of the practical conditions for implementation were in some of our cases crucial in ‘selling’ big ideas within strategic arenas and making sure that operational commissioning took a viable form. Conversely, clinicians who had worked on developing service strategies to address the unmet health needs in the local population played key roles in convincing front-line staff of the underlying rationale and ethos of service innovation.

Introduction to the cases

Within the context of CCGs, our focus was on service redesign in selected areas: mental health, urgent care and integrated care (especially directed at the frail elderly). These tended to be areas of focal interest for a large number of CCGs. Sometimes the way they were framed and presented varied but the core issues were widespread. Hence, we found that many CCGs were working on various forms of extended general practice and this often included attempts to redesign the provision of services for people with long term-conditions and the frail elderly, and these initiatives often involved collaborative work with community services, social services and others. In four of the CCGs we focused on just one main service redesign attempt of this kind; however, in two of them, as there were significant service redesign attempts which matched our core areas of interest, we tracked two initiatives rather than one. Hence, in total, we studied eight service redesign ‘cases’ from the six CCGs. Table 4 shows an outline of the cases.

Below we provide a first level of analysis of the cases; the following chapter provides a further analytical discussion of the insights into the nature of clinical leadership emerging from a comparison across the cases.

Case A: innovating in mental health and urgent care

Case A was one of the inner-London CCGs. The CCG leadership team had been successful in making innovative use of non-recurrent central funding and it had a track record of piloting new models of service delivery. The CCG case analysis below is divided into two parts reflecting two different service redesign initiatives. The first (case A1) focuses on a mental health redesign initiative and the second (case A2) on an urgent care redesign initiative.

Case B: redesigning general practice and primary care

This CCG is located in a part of Birmingham where the health of the population is generally worse than the England average. The CCG, which formed the site of this case study, derived its GP practices from three different former PCTs. The associated variability in practice and expectation is an important element in the case narrative. The CCG inherited huge variation in standards and coverage of care across its patch. The potential for GP practices that were to become unhappy with attempts at reform to renounce membership and join another CCG is also a significant feature. Loss of GP practices meant loss of income for the CCG. This was a very large CCG with > 100 GP practices and, as such, it saw a need to allow the localities a greater degree of influence than was often the case in other CCGs.

Case C: redesigning early intervention services for mental health

Case D: system and multilevel redesign

Case D illustrates many important aspects of the current reality of the leadership of multilevel service redesign attempts in the English NHS. The unit of analysis in this case was the area which became the new STP footprint. It comprised six CCGs, a county council, a city council and a collection of acute hospital trusts and community trusts. They are analysed as one unit here because these particular CCGs had made strenuous efforts to work together and indeed had been prompted to do so.

They all operated within one large, mainly rural, county and had worked together in pairs, in triads and indeed across all six CCGs. Case D covers a population of approximately 1 million people. The health system in the region is in deficit and it is considered not sustainable without radical reform. The context is also one of major change to hospital services following the dissolution of one of its hospital trusts and there were difficulties in recruiting clinical staff in both primary and secondary care.

The health economy so defined was identified as one of the 11 national challenged economies. There was a £140M deficit (2015/16), that is 7% of the funding available. It was forecast that if no change was made this would increase to £240M (11%) per annum over the next 5 years with an accumulated deficit of > £1B. The extent and severity of the challenges helps explain why these neighbouring CCGs were impelled to work together beyond the norm for CCGs nationally. The analysis that follows works through service redesign attempts at different levels and in different arenas starting with GP practices and moving up through localities, the CCG level and then the supra-CCG level.

Case E: redesigning integrated care and urgent care

This case study was carried out in one of the London CCGs. It is located in a densely populated, inner-city area. Its geography was coterminous with its local borough council. The CCG remains in financial balance despite the pressures of supporting one of the most financially challenged acute trusts in the country.

This case study focuses on two key service redesign initiatives: integrated care and urgent care. Both provide useful insights into the origins, nature and outcomes of clinical leadership.

Case F: towards an accountable care organisation

This case (named here ‘Northern Borough’) was selected for two reasons. The first was based on demographic and geographical criteria; the second reason was to illustrate important policy developments taking place jointly in health and social care. The CCG selected was one of the 12 CCGs in Greater Manchester [i.e. it was part of Manchester Devolution (‘DevoManc’)].

The case study CCG with its coterminous borough council has a population of > 228,000. Much of the population is located in areas of high density and relatively poor housing. Both the CCG and council have to deal with large disparities in economic, social and health indicators and situations.

There are three elements of the context which are particularly striking in this case and which affect the opportunities and challenges for clinical leadership.

First, many clinicians and managers and other actors in the wider network have been employed within the region for many years and have a close identity with the place.

Second, DevoManc is having a major impact on health and social care and has required considerable strategic attention from both the CCG and the LA as they work with their counterparts across the region to develop the strategic agenda, the new governance arrangements and the financial arrangements. The CCG leaders in this context have been able to use these developments and opportunities to accelerate ideas about the development of an ACO. However, on the other hand, so much activity at a higher level has tended to remove some of the local ownership and accountability for driving change.

Third, the devolution agenda mandates each of the boroughs to produce a locality plan, which has encouraged closer working between a number of agencies, including health, the LA, the fire and rescue service, Greater Manchester Police and housing associations. The LA in Northern Borough is one which had already developed a strong strategy based on ‘place making’ (an approach to public services well rehearsed in local government in the previous decade) and it has been active in working with the CCG to develop a joint approach. The ACO initiative is able to build on these place-based foundations. The devolution agenda has also led to a leadership development programme across the combined authority, strengthening cross-sectoral and place-based leadership. These are fertile conditions for the ACO initiative.

There is a huge challenge because the budgetary forecast under devolution is less than current spend and so it will leave health and social care with a major financial deficit within 5 years. There are considerable pressures to find ways of integrating services across geographical boundaries, across service sectors (e.g. health and LA), and with system improvements (e.g. improving housing will affect the health side of the budget substantially). Northern Borough with its poor health indicators could be particularly at risk in this.

The pattern of clinical leadership across different arenas

The overall focus is on a profound transformation of the institutions involved in managing the health of the population, as well as on the redesign of particular services. This is reflected in our finding that clinical leadership was most strongly present in various strategic arenas, where clinicians are involved in formulating ideas and theories about new ways of promoting health in collaboration with other agencies. Given this focus on establishing collaborations across traditional agency and professional boundaries, it is important to capture the complexity of the interconnected strategic arenas that clinical leaders worked within. This is shown in Figure 25.

FIGURE 25.

Strategic arenas of leadership in case F.

Leadership is part of the mobilising of attention, resources and commitment to particular plans and values within those arenas.

Figure 25 shows how the clinical and managerial leaders of the CCG were working jointly on conceptualising new kinds of services and mechanisms for delivering better health for the population, building collaborations simultaneously in a number of different directions.

The thought leadership exercised by the GP accountable officer jointly with the managing director drew on long experience of the locality combined with an international and entrepreneurial outlook, to create new visions, values and activities for the CCG. Clinical experience and judgement combined with managerial skills to create a view of health which was innovative and integrative.

Our interviews suggested that this visionary leadership was exercised strongly in strategic arenas. However, its connection with operational commissioning and delivery was, as yet, partial.

The Warm Homes scheme provided an example where thinking and acting holistically had achieved implementation. However, this implementation did not need to involve clinicians, as the scheme involved improving homes. More generally, we found that clinicians often understood that an ACO was in the process of being created. However, they appeared to see little connection between the ACO and the day-to-day improvement of the services they were working on. They appeared to be more embedded in their specialisms and were making incremental progress on service redesign.

Overall, the arena of patient services was dwarfed by the enormity of the DevoManc initiative, which was changing on an almost daily basis during the case study. The DevoManc initiative occupied a lot of the attention of the clinical and managerial leaders in this case study.

Devolution creates a lot to play for political positioning and reputation, budget surpluses or deficits, the quality and standards which will be applied across the combined authority and the governance levers open to the CCGs across Manchester and the LAs across Manchester. If poorly designed, devolution could lead to worsening services. However, if well designed it could create an integrated system across health and social care, bring in extra investment to the city region and improve the lives, the longevity and the health and well-being of local populations and patients.

To engage with devolution required local NHS leaders to work closely with the local authority. The circumstances were fortunate here because such collaboration had occurred for some considerable time in this borough, commencing even before the formation of the CCG. It had been initiated by the Northern Borough council, with its bigger vision of place leadership. The council has acted as a convener, not only of health partnerships, but of partnerships with other relevant sectors, such as housing, the voluntary sector, fire and police. The successful experience of Warm Homes inspired greater confidence to work together further. It appeared to be the council which has steered and opened up the debate about joint governance of the ACO. The clinical leadership of the CCG has embraced this partnership. However, engagement in the political processes of the council (HWB, Health Scrutiny) has perhaps been more statutory than enthusiastic.

The final arena is working with other stakeholders, such as the voluntary sector, the universities, and so on. This arena is rather diverse, and stronger relationships have been fostered with some more than others. The outward-facing and entrepreneurial nature of the CCG has meant a series of connections where the leadership can see key priorities which are relevant to it (e.g. around innovation and service improvement). However, the relationship with the voluntary sector is still being worked on. The voluntary sector is very complex and there are many layers, they tend to work directly with individual GP practices rather than with the CCG as a whole.

Examining leadership in terms of the competing demands of different arenas, one can see that the pull is towards devolution, and towards the council in particular.

Patterns of clinical leadership

In some of the cases, the three arenas could be regarded as operating in harmony – consistent with a logical division of labour governed by the guiding hand of the CCG. However, this was not always the case. Hence, we first of all discuss four of our cases, which can be seen as enacting variations on the theme of a coherent and productive pattern of leadership. Our analysis brings out how various strands of institutional work, needed to achieve service redesign, were performed by clinicians across the three kinds of arena. We then turn to four cases that show problematic features in terms of the degree of coherence between different arenas. Progress was stalled because of the gaps in requisite institutional work in one or more arenas. Our analysis of both sets of cases brings out how achieving coherence or productive interplay between the work going on in each arena was a pervasive challenge, with various dynamics triggering and blocking change at each level.

Turning first to the cases exhibiting coherence (Table 5), a point emerging is that, although clinicians made key leadership inputs in each of the three arenas, there was some variety in the flow of activity.

Factors shaping clinical leadership

Tables 6–8 summarise what was has been achieved through the exercise of clinical leadership across the three arenas in our eight cases, dividing them into the same two groups as above. The tables summarise the factors that were found to help or hinder forms of clinical leadership capable of bringing about service innovations.

We have already seen that the coherence of implementation of service redesign was greater in the four cases in Table 5, and this is reflected in the specificity of the achievements documented. The achievements shown emphasise service outcomes, whereas those in Table 6 mostly emphasise service arrangements that have yet to deliver improved outcomes. However, Tables 5 and 6 emphasise that both groups of four cases involved clinicians grappling with both favourable and unfavourable conditions as they engaged with the challenges of service redesign.

Tables 7 and 8 highlight the following key enablers of effective clinical leadership for service redesign.

The first key enabler concerns the nature of the clinical leadership itself – in the sense of what it is that clinicians see themselves as providing leadership about. For service redesign to be effective, it needs to be based not only on a technical rationale as to how new arrangements will improve health outcomes, but also a moral ethos that appeals to clinicians’ sense of occupational identity. Throughout all of our cases, clinical leadership can be seen as closely bound to aspirations to improve health outcomes and the experience of patients. Variously the benefits being sought include:

• improving the quality and consistency of primary care, thereby decreasing the burden on acute care

• improving understanding of patient preferences and needs, and communication between service providers and patients

• achieving simpler patient journeys and better integration of care both within the health service and with other partners

• improving efficiency and reducing wasted resources

• improving system resilience and delivery.

Such benefits provide the core of a set of values that clinicians in both commissioning and providing roles have used to spread awareness of and commitment to new models of service provision.

We have seen that, in a number of our cases, this moral ethos has become powerfully enshrined within a ‘programme’ arena. When this happens, it is also more likely to be influential within the operational delivery arenas. More generally, a convincing moral ethos can itself serve as a mechanism for binding together the inter-related leadership work that needs to take place within each of the three arenas we have identified.

A second key feature of effective leadership for service innovation was a recognition, by those involved, that there are likely to be successive rounds of defining the nature of the new services and the skills involved. This defining work often involves rethinking the interfaces between previously overdefined and separate services that have become established under a contract-driven and somewhat adversarial model of commissioning. It also requires an interplay over time between the arenas of operational commissioning and operational delivery, as the requirements and performance potential of new service models become clearer. This sort of progressive defining and refining of service models, with clinical input on both the commissioning and provider side, is more likely to occur effectively under pilot arrangements, where competitive, market-driven aspects of commissioning are put in abeyance for a period or where system-driven co-production is emphasised (as in case F). More generally, our cases suggest that achieving effective clinical input requires commissioners to find ways of providing reassurance that they understand how change can be managed collaboratively across the system, rather than competitively, with providers cast as winners or losers. Issues of continued viability of particular provider organisations may need to be faced, but this is more likely to be done effectively if commissioners join providers in thinking through what a viable future might look like for them.

A closely related factor that supported the development of clinical leadership across the three arenas was the presence of established formal and/or informal clinical networks. Innovation in primary care in case C built on established relationships between many practices and active locality structures. Innovation in the alliances in case A1 built on established relations between acute providers. Even in the less developed cases, such as case E1, achievements have built on existing relationships.

Finally, Table 8 suggests a number of reasons why achieving coherence in clinical leadership across the three arenas may be difficult.

Elaborate and far-reaching service redesigns over a wide geography can preoccupy clinical leaders when creating plans in strategic and operational commissioning arenas (points 1 and 2 in Figure 24). This sometimes detracts from the development of operational detail. It may also deflect effort away from building normative networks among front-line provider staff (cases E1 and F).

Additionally, committed normative networks may emerge within providers, particularly among GPs who have been inspired by the aspirations of CCGs, but perhaps found that the realities of opportunities for influence have not lived up to their expectations. Such situations can lead to confusion and something of a vacuum at the operational commissioning level (point 2, see Figure 24), as delivery leaders recruit different NHS strategic initiatives to serve their purposes (case D).

Notably, in case D, innovations in primary care were driven not by GPs as commissioners using the CCG as the lever, but rather by GPs as providers using GP federations as the vehicle for change. There were service innovations built around telephone triage, new workforce designs, self-care, targeted work with the frail elderly using specialist teams of GPs with special interest, pharmacists and specialist nurses. Some of the major clinical innovators involved in these initiatives were of the view that the CCGs were simply not delivering and the service and the patient simply could not wait for them. Thus, they said, the provider side needed to get on with the redesign and present it to the commissioners as a new offer. Although these initiatives were undoubtedly examples of clinically led service redesign, they were often stymied by the lack of a receptive and sufficiently resourced operational commissioning forum to consider them.

Conclusions

This chapter has analysed the role of clinical leadership in our eight cases in terms of three arenas, concerned with strategic commissioning, operational commissioning and operational service delivery. We have also made a distinction between the leadership work of instigating service redesign and that of implementing new models or concepts of service delivery. In addition, we examined the range of ways that these activities can take place across the three arenas. A number of key points are worth bringing out by way of conclusion to our comparison of the eight cases.

First, the leadership work of crafting operational detail is bound up with the operational delivery arena – without leadership work within this arena, operational solidity is unlikely to emerge. However, this institutional work of defining operational detail requires interchange with the operational commissioning arena, so that the staff and other resources or delivery are appropriate and also so that there can be iterative refinement of the overall concept and its ethos.

Second, and perhaps more surprising, the leadership work of envisaging and articulating new service concepts can begin in any of the three arenas and often involves individuals who can move adroitly between them. We saw new service concepts being taken up to the strategic arena by clinicians who were also engaged in committed work in operational arenas, as well as cases where clinicians working mainly in strategic arenas formulated big ideas and found formal and informal ways of shaping powerfully the activities of colleagues in the other two kinds of arena.

Above all, our analysis brings out the key role played by operational commissioning arenas for steering service innovation. Arenas such as programme boards appear to offer a forum where clinical leaders in CCG commissioning roles and in provider roles come together to integrate the institutional work of creating new models of service delivery. In order to do this, they can be seen as bringing clinical expertise and experience to bear in reconciling a number of perspectives which are potentially in conflict with one another. These include:

• thinking differently about what established clinical professions do, in the context of services designed to address the needs of members of the public in a holistic way; tackling identified public health challenges rather than providing a service as defined by established clinical specialisms

• developing new or modified professional identities and skills sets; clinical leaders in commissioning and provider roles became engaged in practical debate about the skills and sense of priorities of particular clinical roles

• preserving and enhancing the expertise base of established clinical workforces; in some of our cases, provider clinical leaders took up a key role of working out how the expertise they represented could continue to be useful and relevant in a new service delivery model

• identifying where national-level funding schemes offer opportunities or incentives for investments in new models of service; in some cases, the work of making sense of, and capitalising fully on, a plethora of national initiatives and sources of funding demanded a great deal of attention

• preserving the income streams of established clinical provider organisations; in a number of cases both commissioners and providers found themselves dealing with complexity around whether or not to continue to support an established provider or advocate it be replaced by something different that might serve public health needs better.

Grappling with these tensions involves much more than mediating between a managerial and a clinical perspective, which is one established notion of the work of clinical leadership. Our analysis of the work of programme boards suggests that clinicians and non-clinicians on such boards find themselves mediating between a variety of different managerial perspectives (e.g. looking at the best use of limited commissioning funds alongside how to preserve the viability of provider organisations), as well as simultaneously mediating between a variety of clinical perspectives (how to understand the future role of GPs or clinical psychologists from a provider perspective and how to reconcile such provider perspectives with an understanding of emerging public health needs which do not fit well with existing services or specialisms).

One of the key lessons from our cases is the function of programme boards in providing a kind of adaptive leadership forum where complex dilemmas can be tackled through a process of dialogue, guided by an ethos of commitment to public health. Solutions to such dilemmas need to be discovered rather than imposed.

This role of programme boards is particularly significant given the fact that, as we will see in the next chapter, these kinds of arenas do not exist in some health-care systems abroad. Although the original conception of CCGs emphasised the importance of their governing bodies as the place where the clinical voice would direct commissioning strategy, our cases demonstrate that this depends on carefully constructed operational commissioning forums, such as programme boards. In order to achieve this, we saw commissioners in these operational commissioning arenas finding ways to set aside models of market-based commissioning and instead seeking collaboration with providers to establish pilot arrangements for new models of care. These attempts frequently seemed to rely on using non-recurrent funding.

The fundamental work of achieving effective service innovation involves work occurring across the operational commissioning and operational delivery arenas. One constant leadership task addressed within strategic commissioning areas is the authorisation and vesting of resources in the other two arenas. In some cases, the work of making sense of, and capitalising fully on, a plethora of national initiatives and sources of funding demanded a great deal of attention.

The findings make clear that the integration of clinical leadership across the three arenas can be an uneven and lengthy process. This has important implications for the speed of progress in service innovation that policy-makers should expect.

Modes of clinical engagement and clinical leadership

The first research question asked about the range of clinical engagement and clinical leadership modes being used in CCGs. One kind of answer to this question was given in the survey results chapter (see Chapter 3), the case study chapter (see Chapter 4) and the cross-case comparisons chapter (see Chapter 5). Engagement ranged from minimal to extensive. A significant proportion of GPs chose not to engage with their CCG. This tendency of disengagement grew slightly between 2014 and 2016. Yet, on the other hand, the research also uncovered some clinicians who were very active in the process of leadership of service redesign.

As noted in Chapter 5, this institutional work took place in three main arenas: strategic commissioning at CCG board level; operational commissioning at programme board level; and practical implementation work at service delivery level. Across the cases we tracked and clarified the key achievements, the factors which facilitated clinical leadership in these instances and the challenges which they had to overcome. As shown, the main instances were found in extended service and raised standards in primary care; new designs in integrated care, especially for the frail elderly; innovations in urgent care, which offered alternatives to A&E; and new service offers in mental health.

Given the relative autonomy inherent in the professional work of doctors, there was normally an understanding that some degree of persuasion would be required in order to switch patterns of service organisation and provision. ‘Leadership’ therefore was often seen to require communication of the need for change, a visualisation of the possible solutions to the identified problems and a roadmap of how to move towards the desired destination. Doctors tended to demand ‘evidence’ for each of the three steps. The various ways in which this game was played provided the drama that unfolded in each case. Above all, our cases all suggested that ‘evidence’ and rational persuasion was not enough by itself. Leadership for service innovation also involved the building of a network of clinicians who shared an ethical or moral commitment to a new model of more integrated service provision. Although this is perhaps not in itself surprising, our cases are revealing in the variety of ways these ‘normative networks’ came to be constructed.

The literature on this subject comprises a mix of prescriptive and descriptive approaches. A number of writers have advocated proceeding in a collaborative, consensual and adaptive way. 42,50,52 As Spurgeon et al. state in their book on medical leadership:

We favour a model of shared or distributed leadership . . . this is about the quality of interaction rather than formal positions and is evaluated by how well people work together. It is where everyone is engaged in acts of leadership, where communication and making sense of conflict ensure that the process is democratic, honest and ethical [and] based on evidence and professional judgement

Spurgeon et al. (pp. 6–7)42

Descriptive accounts often show situations where the predominant pattern is rather different. Detailed research of change in health-care settings reveals the influence of leadership by two or three at the strategic apex. 56,87 This phenomenon, in earlier literature, was referred to as the work of a ‘dominant coalition’. 88 Evidence from our case studies showed that such coalitions were very much in operation in CCGs. In one of the cases (case B), the three at the top were all GPs (the chairperson, the accountable officer and the vice chairperson). In other cases (e.g. case E), the dominant coalition comprised a GP chairperson and a manager occupying the accountable officer position, working in tandem. Even in the cases cited, implementation of new service modes required more plural forms of engaged leadership. In case B, for example, the required reforms to primary care required a sufficient critical mass of willing implementers for peer pressure to have an impact on those GPs seeking to hold on to the status quo.

These issues concerning stability and change in organisations have a significant presence in the literature. The tendency for organisations which operate in a shared environment to adopt similar practices has been noted by organisational researchers. 89,90 Hence, there tends to be a propensity for organisations to replicate known and accepted ‘recipes’. This may be because it is easier to maintain legitimacy this way and because it can be easier to mimic existing practices. 89 However, the more that persistence and stability is explained, the harder it is to explain change. Those changes that do take place may themselves be characterised by a certain conformity – conformity, that is, to an accepted model of change. It is the cases of divergence from existing institutions and institutionally promoted templates for change that are harder to explain. 69

The case studies revealed two types of change: conformist innovation (that which followed templates and guidance from the centre) and deviant innovation (that which diverged from directions set by the institutional status quo). The latter may require actors to distance themselves from accepted norms. In such cases, the role of ‘enabling actors’ and their location in an institutional field assume importance. 67,90 Actors at the margins, for example, who have less invested in the status quo, may be prompted to initiate such action. However, on the other hand, they are less likely to have the resources to make a major impact. Disruption may occur to the role divisions (jurisdictions) of organisations (e.g. the boundaries between primary care and secondary care) and/or between the jurisdictional boundaries of professional groups. In the NHS, actors/change agents are likely to be interfacing with, and having an impact on, both of these. Resistance to change may come from both of these interests.

Evidence from our cases suggests that disruption and the imagining of new forms of service was additionally complicated by the fact that in the NHS it is far from a simple matter to map which actors are more embedded in the status quo and which have a greater stake in challenging it. National policies and strategies emanating from senior levels in NHSE profoundly challenge the status quo in terms of the boundaries between primary and acute care. At the same time, front-line clinicians in district general hospitals are often the most passionate advocates of shoring up the status quo in terms of what happens in the acute sector. So, new models of service delivery can come both from apparently entrenched senior actors (such as those instances in cases B, E and F where the top two or three provided the vision and the impetus) and from more marginal actors (as in cases C and D where enthusiastic GPs with no formal place in the CCG hierarchy used their local knowledge to drive a path for change). Neither one could be said to be inherently superior. They each faced challenges. The former approach needed to win local commitment. The latter, ground-up approach, needed to win resources and support from above.

The coexistence of competing logics opens up space for disruptive challenge and for the creation of new forms. Insofar as elements of competition have been allowed, there has been scope for new service forms to be introduced by ‘new entrants’, such as new primary care provider groups run by GPs. Their position in the field means that they can deploy resources based on expertise and local knowledge and can, credibly, bid for contracts from commissioners of a kind which represent new modes of service provision. These new elements may include improved access, extended hours, multidisciplinary teams and an extended range of services in community settings. And all at potentially lower cost.

Our cases revealed instances where clinical leaders within CCGs (e.g. nominated clinical leads for specified service areas, GP chairpersons or GP accountable officers) drove change very much in line with approved models approved by NHSE. In these cases, leaders could deploy the allocated resources (managerial and financial) to deliver the plan. (Persuading all members to fall in line was not always so straightforward.) These instances could be seen as conformist innovation. Indeed, to ‘do nothing’ – to merely persist with established legacy behaviours – could be regarded as somewhat deviant. However, given the complexity of the NHS, matters were not always quite so simple. Our cases revealed numerous examples of leadership of service redesign where the challenges were more complicated. ‘Grass-roots’ innovation by enthusiastic locality groups or pioneering specialists had to negotiate the complex web of interest groups that might favour existing arrangements. The CCG might itself support the status quo because unpicking the tangled web of payments, contracts and systems maintenance appeared too daunting and they saw themselves as having more pressing immediate priorities.

Commissioning as a platform for clinical leadership

The second question asked about the extent and nature of the scope for clinical leadership and engagement in service redesign that is possible and facilitated by commissioning bodies. This question places the focus on the enabling conditions. The HWB aspect is the easiest to answer. These bodies rarely played a significant part. Nor did clinicians engage in any meaningful way with these bodies. Representatives from CCGs at HWBs tended to be accountable officers and/or chairpersons. Of more direct interest was the role of the CCGs themselves. There were two key aspects to this. The first of these was within the CCGs: how much influence were clinicians able to exercise? The second aspect was the power and influence of CCGs as institutions: what weight did they carry among the many other players in the landscape? Were they able to make a difference?

In formal terms, CCGs are membership organisations; nominally GPs are ‘in charge’. In reality, it is a much more complicated picture. There were a significant number of cases where managers acted as the most influential players. However, this was by no means a universal phenomenon. Our data point to cases where GPs exercised extensive influence over the strategic direction of the CCG as a whole and significant influence within specific service areas. In some of the cases this was because influential clinical figures took up roles as chairpersons or accountable officers and steered the CCG in a particular strategic direction. The case studies which focused on reform of primary care, for example, illustrated how leading clinician managers occupying hybrid roles pursued the kinds of changes which reflected the visions set out in Liberating the NHS3 and those wanted by NHSE. The puzzle is why there were not more cases of this kind. The answer stems not only from the expected difficulties in carrying along the GP membership but, additionally, from the complex interplay of diverse institutions each with their power basis and each part of a wider web of services underpinned by payment mechanisms, which were found to be difficult to unravel.

The scope for service redesign using the mechanism of these local commissioning groups was thus checked by numerous sources of inertia. Agents rooted in institutions can be expected to conform to the rules of those institutions; yet, as individual actors, they also have scope for the exercise of agency. This duality has been termed the ‘paradox of embedded agency’. 91 Explanations of why one or the other side of this paradox is enacted may be facilitated by referring to a mix of the individual actors’ location within the various institutions (organisational and professional), as indicated by Battilana,67 and also by the orientations and values of the individual actors.

Regarding the influence of CCGs as institutions in a competitive institutional landscape, the picture is again mixed. We found examples where CCGs were marginal, peripheral players.

The benefits being sought from clinical leadership

The third question asked about the range of benefits being targeted through different kinds of clinical engagement and leadership. The most straightforward answer to this is that there was very evident commonality in the declared objectives of the would-be service redesigners. Integration of service was the big theme and care closer to home and away from secondary care was another.

The findings suggest that the creation of CCGs did, to an extent, enable and prompt increased, and more potent, clinical leadership. As shown in the main body of the findings in this report, there were numerous examples of clinicians – along with managers – engaging seriously with service redesign and making a real difference to practice and to outcomes. However, this proved to be very irregular and uneven. Nor, after > 3 years of operation, did clinical leadership using the CCG platform, nor indeed CCGs themselves, live up, overall, to the level of expectation generated around the time of their inception. Part of the reason for this contingent and conditional performance was the degree of extraordinary turmoil in the wider context. The nationally driven agenda moved on. This piece of institutional work had to compete with other, newer, initiatives.

The research evidence, drawn from both the surveys and the case studies, revealed a number of weaknesses in the concept of GP-led commissioning groups. Insufficient numbers of GPs were willing to step forward to take up commissioning roles. There was regular reference to the paucity of the ‘leadership pipeline’. In addition, with regard to those GPs in such roles, there was concern about the amount and quality of training and development.

During the course of the study it was evident that GPs were showing more enthusiasm for leadership of the new provider bodies, such as the federations and the extended care delivery bodies. Hence, our work shows that clinical leadership seeks out spaces of influence almost regardless of the particular institutional arrangements. This is highly relevant because it means the findings in this report are likely to be generalisable beyond the life of CCGs. The findings point to the ways in which clinicians cope with, and shape, institutional change.

A further weakness stemmed from the size and limited influence of the CCGs. They were seen to be too many and too small. In the latter stages of the study it was evident that many CCGs were seeking to work collaboratively with their neighbouring CCGs and were taking steps to establish arrangements for a single shared accountable officer and a common commissioning body. The results of the second national survey showed that large numbers of governing board members did not expect their individual CCG to survive in the long term. The large acute providers continued to exercise considerable influence and the CCGs found it difficult to reshape the scope of services they offered – either because they were but one of a number of small commissioners or, conversely, because as a main commissioner they could not be seen to ‘destabilise’ their local secondary provider.

The construct of ‘leadership’ is just one lens through which the challenges and operation of the health system can be analysed and understood. A systems perspective would direct attention to issues of equilibrium and disequilibrium, interdependencies and adaptation in response to resource shifts. Similarly, changes in service models can be attributed to knowledge flows and power distribution. Important agents in both respects are the management consultancies. The large international firms enable and impel knowledge shifts in an important, but relatively hidden, way. The firms work behind the scenes and reference to their influence is rarely made in board papers and related strategy documents. Moreover, the firms work at multiple levels: simultaneously at national level (shaping policy changes) and at regional and local levels (including work with individual service providers and individual commissioning organisations). Enactment and delivery of their models normally depends on co-operation and engagement with clinical practitioners and indeed with managers. However, whereas managers can comparatively more easily be directed to conform with a policy shift, clinical professionals with their elements of autonomy, ethical codes and specialist knowledge require more subtle handling. Thus, enlisting local clinicians to the task of mobilising effort and making ideas work in practice is a vital requirement. The twin tasks of legitimising the direction of travel and the destination while also demonstrating how it can work in practice (implementation work) are crucial requirements. These tasks can merit the label leadership.

Enablers and barriers

The fourth question concerned the forces and factors that serve to either enable or block the achievement of benefits in different contexts and how appropriate are different kinds of clinical engagement and leadership for achieving effective service design. In this report the enablers were shown to be strong working relationships between key figures in and beyond the CCG – most especially when there was a clinical chairperson and an accountable officer working to a common agenda with a relationship based on trust and mutual respect. Intriguingly, prior working could operate in contradictory ways. In some of our cases, the CCG leaders had a long history of working with each other and they built on that track record. Yet, that was not always a positive. In other cases, where CCGs emerged from diverse groups and the organisation was thus starting anew, the incoming leaders reported that they could introduce a new broom with no regard to any previous compromises. The blockers were found to be many: complacency; lack of vision; lack of resources; feelings of disempowerment in the face of dominant providers; and new initiatives from above seemingly taking over the agenda for change. As our survey data clearly showed, the CCGs rated by NHSE as ‘inadequate’ or ‘requiring improvement’ were also those where respondents felt they had less influence – both as individuals and as organisations.

International comparisons

Finally, the fifth question was about the resonance, relevance and learning across health systems in different countries. To answer this question we shared our findings with expert scholars in a range of countries and sought their responses. Even though CCGs are unique, the underlying issues examined in this project found resonance in other systems. Below we give some examples.

The Quebec health system in Canada had sought to address similar challenges of an ageing population and the need for long-term care with new institutions – Health and Social Services Centres. These were designed to integrate acute, community and home care. Similar to the UK NHS, it tried to shift from a service-based approach to a population-based approach. It was found, as in our study, that actors at managerial level were needed to do the kind of ‘institutional work’ we discussed in order to translate grand policy into meaningful action. There, too, the ambiguities, contradictions and gaps had to be attended to by skilful agents. They too had to undertake structural, conceptual, operational and relational work to engage front-line staff in effective implementation. However, managers were expected to take on much of this work and there was rather less of an expectation that it would be done by clinicians.

Our colleagues in Germany and the Netherlands observed that our CCGs are somewhat similar (in some respects) to ‘practice networks’ in Germany and to ‘care groups’ in the Netherlands – both are organisations with 50–150 GPs which represent and put forward the GP voice in negotiations with health insurers and the provincial governments which, in a sense, ‘commission’ health provision. The groups are not vested with the same statutory power to act as commissioners as in England, but they do put forward a collective viewpoint. Germany and the Netherlands both have complex health-care systems with distributed decision-making in which health insurers have an important role. The German insurance groups monitored activities, payments and performance. GPs (and their organisations) negotiate with multiple health insurers, who may arrange different services in addition to the standard package. Some GPs have organised themselves in networks (Germany) or care groups (the Netherlands) for these negotiations. In Germany, health care is largely shaped in the various Bundesländer, so policy-making is at least at two levels: state and country. Our triangle of arenas of practice find resonance at the practice level and to some extent at the policy level, but our second arena (programmes of commissioning) was of course absent.

We asked about lessons for the UK. We were told that, in the Netherlands, health-care costs exploded after market principles were introduced in health care in 2006. The cost increases slowed down in 2011 after maximum budgets were reinforced for hospitals and budgets for home care were cut substantially a few years later. Both developments were unrelated to GP care but they increase pressure on GPs. GPs are well established in the system but perceive increased administrative control on their practice in recent years. In 2015, a large majority of GPs revolted against health insurers and the ministry of health because of the high administrative workload and unequal position in negotiations with health insurers.

Another expert in the Dutch system noted that some experiments in the Netherlands had resonance with our study. He noted some regional collaborations between hospitals and GP practices. These are often located near a hospital emergency room and in some cases even shared an entrance. They are funded by the local insurer (there are four large insurers that represent 90% of all patients and traditionally ‘own’ certain regions).

It might be argued that, in the light of our findings, the CCGs have a de facto role somewhat similar to these practice networks and care groups. In reality, their market power is limited and their role vis-à-vis NHSE could be seen as subsidiary and circumscribed. Using this analogy, the relationship between CCGs and NHSE could be likened to ‘care groups’ interfacing with a proxy insurer. Aspects of planning, allocated budgets and quasi-market principles are all in play. Similarly, in the Netherlands, the same debate about the relative merits of market versus co-operation/collaboration could be found.

In Sweden, GP groups were reported as jointly developing new models of care with hospitals. However, with regard to primary care services, these experiments tend to be limited to a few of the larger practices acting alone and the population coverage and scale are small compared with some of the initiatives in the UK. In the USA, we were told, despite the high-profile cases such as Kaiser Permanente, the dominant model is of professionally managed organisations and systems without any expectation that GPs would be in a position to lead significant changes. From that perspective, the English CCG experiment simply looks too radical.

These international examples reflect GPs acting in groups and engaging in service redesign, albeit as partner providers rather than commissioners. This is a pattern increasing in importance in England and may reflect a shift in emphasis and role for local GP groups here.

Findings

We summarise first the main findings relating to CCGs, then, second, the main findings relating to clinical leadership in and around CCGs.

Limitations

The research underpinning this report included a vast array of investigative activities across a very large number of CCGs. Nonetheless, such is the variety and complexity of the work of CCGs that it is difficult for any report to claim to fully capture and reflect the full ‘reality’ of CCG work and the leadership attempts therein. The six CCG cases are not necessarily reflective of the 2009 CCGs in England. That said, the detailed cases were not intended to be a representative sample of all CCGs. Indeed, as mentioned, they were selected through theoretical sampling and there was a bias towards CGGs where there was some evidence of meaningful activity. The wider survey, which covered all CCGs, allows a broader picture and much of the evidence from that source pointed to numerous instances where there has been much less activity than we record in our cases. So our casework is not statistically representative of CCGs, but it does help reveal the pattern of activities and factors which allow GPs to make a substantive difference – if they are minded to do so.

Implications for practising clinicians, managers and other local actors

The main practical implications to be drawn from this research project are as follows.

• Managers and clinicians alike seeking to drive service change using CCGs need to attend to the alignment of work in the identified different arenas if their innovations are to be effective and sustainable.

• Practitioners need to recognise that they are operating in a very different institutional field from that which pertained when CCGs were launched. Past assumptions about power and influence may not be valid. Major new initiatives emanating from national level, such as STPs, Vanguards and the promotion of ACOs, signal that the role of CCGs has been diminished. Work needs to be done in this fourth arena.

• Practitioners in and around CCGs should seek to capture, preserve and build on the best examples of what has been achieved, while also learning about the processes which brought these about. The lessons will be useful in new contexts even if CCGs do not survive or become much reduced in their role.

• Process innovators need to recognise that managers and clinicians are both required to work in tandem in order to make service redesigns stick.

• The survey revealed that many individuals currently serving on CCG boards are heavily inclined towards the power of commissioning and contracting; the emergent emphasis on integrated services and collaborative working means that new attention has to be directed to the rather different ways of working and the associated sets of competences.

• Clinicians with influential roles within strategic commissioning arenas – most especially on CCG boards – should see their role as making decisions to vest resources in new models of care that meet population health needs more effectively. Learning from the cases suggests that initiatives work best when there is commensurate supportive activity under way in operational planning and practice delivery arenas. Most crucially, clinical leaders on the commissioning side of programme boards need to make sure they engage creatively with influential GPs and acute provider clinical leads who are involved in creating the operational detail of new or improved services.

• Clinical leaders responsible for implementing new service concepts need to ensure that they are engaged in building normative networks of clinical colleagues committed to the new way of working.

Service redesign is not an end in itself; rather, it should be a response to identified problems and opportunities for service improvement. Actors in the current system are under time pressure and so it is especially important that they are able to direct their energies in effective ways. Exercises in establishing common purpose and reanalyses of the state of the system can be useful but they can also be excessive. Launching reviews and initiatives was experienced by some as too easy and too frequent. The early stages of projects and programmes are the easy part; follow-through and the realisation of effective impacts are the difficult parts. The problem of the plethora of initiatives is not resolved simply by producing documents claiming alignment with other ongoing programmes and projects.

Implications for future research

When writing the proposal for this research project we stated that even if CCGs did not survive there was merit in studying how managers and clinicians would behave under these kinds of regime. We regarded it then, as we do now, as a valuable opportunity to take advantage of a bold, large-scale, natural experiment. No other system has given GPs such extensive commissioning powers. There was potential for radical change and we wanted to explore how these newly privileged actors would undertake the institutional work of disruption and rebuilding that lay in prospect.

In practice, we found that action, in the main, did not match initial expectations or plans. Institutional stickiness in the wider system alongside competing logics and forces meant that attempts at radical change were often blocked. Yet, as shown, we did identify and classify many rich instances of clinical leadership in three main arenas: the strategic, the operational level of programme boards and the practice level of service delivery. The research agenda emerging from this work relates most obviously to how the newly emergent bodies such as the STPs and the extended primary care formations and ACOs, will operate, and with what impact.

However, in addition, the other implication for future research is to delve deeper into the forms of clinical leadership which we identified. These operated in different arenas and they seem capable of recurring with, or without, altered forms of commissioning and collaborative planning in health care in the future. Whatever institutional form health-care governance and management may take in the future, many of the processes we uncovered and the capabilities inherent within them will resurface. Future research therefore can usefully focus on these enduring elements: how normative commitment is constructed; how front-line clinicians are engaged; how alliances across professional groups and organisations are built; how existing provider identities are handled while encouraging greater professional exchange in the interests of patients and public.

Another theme for future research that emerges from this work is how the established institutional hierarchies (most notably the acute hospitals, especially when they are foundation trusts with budgets to defend and targets to meet, plus also the general practices) will meet on the common ground of shared population-based health and well-being as the supposed priorities, when they continue to feel the tug of professional identity, professional jurisdictions, institutional survival and shortage of resources. The bases of negotiated order, whether or not contractual and/or relational, will need exploring.

Contributions of authors

John Storey (Professor of Management) conceived and designed the study, conducted interviews, designed the national surveys, synthesised the results and authored the final report.

Richard Holti (Senior Lecturer in Human Resource Management) helped design the study, conducted interviews, helped design the national surveys, synthesised the results and authored the final report.

Jean Hartley (Professor in Public Leadership) helped design the study, conducted interviews, helped design the national surveys, synthesised the results and contributed to the final report.

Martin Marshall (Professor of Healthcare Improvement) helped design the study, conducted interviews, helped design the national surveys, synthesised the results and contributed to the final report.

Tatum Matharu (Research Fellow) conducted interviews, helped design and administer the national surveys, synthesised the results and contributed to the final report.

Data sharing statement

All available data can be obtained by contacting the corresponding author.

Disclaimers

This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health.

Training and development

Respondents were presented with a scale from minimal to major training and development provision. The average (mode) answer in 2016 was ‘an uneven pattern, some have some have not’. Only 8% of respondents reported that there had been major initiatives to provide training and development (Figure 27).

FIGURE 27.

How much training and development have clinical leaders received?

Figure 28 suggests, however, that there has been a decline in GP engagement with leadership in and around CCGs.

FIGURE 28.

Trends in GP engagement and leadership (1 = low agreement, 5 = high agreement).

Once again we see the mixed nature of the picture. Whereas previous charts (e.g. Figure 20) have shown reason for an optimistic picture of clinical leadership in and around CCGs, Figure 28 shows a degree of pessimism. There was an overall view that GPs are now less engaged in leadership than they were previously.

Yet, when faced with the statement that ‘achievements of my CCG to date have more than matched expectations at the time of authorisation’, respondents, on average, agreed (3.4 on a 5-point scale, with 5 being high agreement).

There was broad agreement that, increasingly, service redesign is being tackled above the CCG level and that co-ordinated commissioning across multiple CCGs was increasingly common.

Data gathering for main cases

There are two sets of topics to be covered in our data gathering.

The first set relates to relevant contextual issues (the kind of challenges faced by the CCG and the way it is currently organised, such as the extent of collaboration with other CCGs and the level of influence and engagement by clinicians in general terms).

The second set relates to investigation of particular service redesign initiatives. In this second set, some typical questions are also set out that might be used in interviewing key actors. Data will also typically be gathered through analysing documents (e.g. of relevant programme boards), and observing relevant meetings. Two project team members per case.

Context topics

There is a set of issues that we need to be informed about. Data can be gathered through a variety of means: board papers, interviews with CCG executives and other key actors, observing meetings. The following list is a guide to topics that need to be covered.

• In what service areas, and how, has the CCG actually had most impact? Where has the CCG made a difference (overall)? What is the degree of influence locally? System integrator/leader?

• Current main developments/issues (e.g. co-commissioning, federations, outcome-based commissioning).

• Legacy effects (e.g. of former PCT).

• Local challenges (e.g. nature of local health economy and of providers).

• Impact on primary, secondary, community services, integration.

• Where is the leadership located (i.e. CCG board, HWB, localities or at another level such as CCG collaborations)?

• What does the leadership look like? Is it realised through one particular individual, a particular set of people (how many/who) or is it more evenly spread?

• Relevant issues/influence of key surrounding institutions: NHSE, Monitor/NHS Improvement, CQC, LA.

• Engagement of GPs/members.

Particular service redesign initiative

Prime contractor arrangement and outcome-based commissioning

Table 12 shows a brief overview of the answers with percentages rounded to the nearest 5%.

The answers to this question suggested some fundamental differences in the beliefs and perspectives held by those who hold positions on CCGs. As Table 12 shows, the majority leaned towards a view that commissioning through the use of contracts with clearer specification of outcomes was the surest way to proceed. Even where it was not currently in place, these respondents ‘remained hopeful’ and were committed to the general principle and logic. A surprisingly high number of CCG board members (10%) admitted that they did not know what the terms meant. Another significant group (around 15%) comprised persons opposed to these contracting approaches in principle and/or viewed them as too complicated, impractical and overhyped. A significant number of these sceptics were more attracted to what they saw as emerging models such as MCPs and the STPs, which gave hints that they leaned more towards planning and collaboration rather than completion and contracts. Other responses were:

I think this will take longer than 2–3 years to have an impact. It is difficult to get good reliable outcome measures in a number of areas.

I think the major issue will be that acute providers will have a disproportionate influence, and too much effort will be spent on managing this.

Prime contractor arrangements could be hugely important due to the risk around sustainability of individual providers and the blurring of responsibilities for sector based activity (i.e. acute, community, primary care). They will only work, however, if there is a strong and sustainable provider in the economy who can lead on them.

Wait to see, the power still seems to be with providers, and will continue to be so while the reorganisations are targeted at commissioners for political expediency.

Other respondents suggested the potential value of outcome-based commissioning:

It is very important. We need to move away from activity commissioning as this generates unsustainable levels of often ineffective activity – ‘failure demand’. Creative solutions will require a focus on the patient and their desired outcomes.

The current PbR [payment by results] framework and mechanism is a significant limiting factor on real transformation of service delivery.

Need to be realistic and flexible about commissioning for outcomes. This will require a review of the ‘payment systems’ and needs to be focussed around integration and must be a collective responsibility.

The future of Clinical Commissioning Groups

Finally, the survey asked an open-ended question inviting these CCG board members to share their expectations about the future of their CCGs and CCGs in general.

The notable feature arising from answers to this telling question is that the vast majority of respondents (65%) judged that CCGs – the organisations on which they were serving and devoting considerable amounts of their time – will not survive. Others (30%) expressed huge uncertainty about the future. Only a small minority of respondents said that they expected CCGs to continue. This is a surprising finding given the roles of these respondents. This was not a survey of GPs in general or of nurses and others of the > 1.2 million NHS workforce, but the select few who had stepped up to the task of leading these organisations and who had invested their energies into them. If only to help resolve tensions arising from cognitive dissonance, one might reasonably have expected a more optimistic and positive assessment of the future of the CCGs from this population group.

Of those large numbers who expected the demise of their institutions, there was a divide between those who viewed this eventuality as regrettable and those who judged it appropriate. Among the latter was the view that the clinical leadership role had not been sufficiently defined and grown, ‘Too much money spent on paying clinicians to do pure management roles’ and ‘It’s a flawed model’. However, others lamented the decline, ‘If they were allowed to commission services locally and in the best interest of patients then the mid- to long-term future could be significant!’

To some extent, the vicious circle described above was again at play. The perceived neglect of CCGs and the huge emphasis on STPs and devolution of health and care to LA areas perhaps not surprisingly had its consequences, for example as expressed in the answer ‘There is complete apathy among GPs; our morale is very low’. The CCGs were ‘Unlikely to survive due to lack of clinical engagement’.

There was a sense that CCGs were the wrong size – too small for core purposes but too large for local delivery – hence the phrase ‘A change to localised MCPs on the one hand and more centralised contracting arrangements on the other’. There was a view that they would ‘Merge then fold’.

Nor is it only a question of size and footprint. Questions were also raised about the continuing rationale. Some detected a ‘Blurring of the provider/commissioner split’.

This was associated also with the view that ‘I sense the centre has given up on CCGs’ and that ‘NHSE ignores CCGs most of the time anyway’. These responses, and others shown in Table 13, suggest that the future for CCGs was felt to be uncertain among many of the senior players who are needed to make them work.